Laura A. Peterson

Clinical Presentation, Investigation, and Management of Pulmonary Vein Stenosis Complicating Ablation for Atrial Fibrillation

Background—Although segmental or circumferential ablation is effective in eliminating pulmonary vein (PV)–mediated atrial fibrillation (AF), this procedure may be complicated by the occurrence of PV stenosis. Methods and Results—To establish the clinical presentation, diagnostic manifestations, and interventional management of PV stenosis, 23 patients with stenosis of 34 veins complicating ablation of AF were evaluated. Each patient became symptomatic 103±100 days after undergoing ablation. In 8 veins, the ablation producing the PV stenosis was a repeated procedure for continued AF. Nineteen patients presented with dyspnea on exertion, 7 with dyspnea at rest, 9 with cough, and 6 with chest pain. On multirow spiral computed tomography examination, the narrowest lumen of the affected PVs measured 3±2 mm compared with 13±3 mm at baseline (P≤0.001). The relative perfusion of affected lung segments on isotope scans was reduced to 4±3% of total perfusion compared with 22±10% in unaffected segments. At percutaneous intervention, these veins showed 80±13% stenosis, with a mean gradient of 12±5 mm Hg. This was significantly reduced to a residual stenosis of 9±8% (P≤0.001) and a residual gradient of 3±4 mm Hg (P≤0.001). Twenty veins were treated with balloon dilatation alone, whereas 14 veins were stented with standard 10-mm-diameter bare-metal stents. Although the symptomatic response was nearly immediate and impressive, 14 patients developed in-stent or in-segment restenosis, requiring repeated interventions in 13. Conclusions—Percutaneous intervention produces rapid and dramatic symptom relief in patients with highly symptomatic PV stenosis after radiofrequency ablation for AF. Nevertheless, alternative treatment methods will be required to decrease recurrent in-stent or in-segment restenosis.

The impact of admission to primary versus tertiary care VA medical centers on outcomes following acute coronary syndromes: The VA access to cardiology study

Background: There is concern that ACS patients admined to primary care hospitals (without cardiology services) may be at risk for worse outcomes compared to patients admitted to tertiary care hospitals (with cardiology services). We compared the outcomes of ACS patients admined to primary versus tertiary Veterans Administration hospitals. Methods This was an observational cohort study of 2,322 VA patients with AMI or Unstable Angina from 24 VA hospitals (10 tertiary, 14 primary centers). Univariate analyses were used to compare the baseline characteristics and outcomes of patients admitted to primary versus tertiary care hospitals. Outcomes included in-hospital and 7-month mortality, and 7-month revascularization rates (PCI or CABG surgery). Results There were 1470 patients admitted to tertiary centers and 652 patients admitted to primary centers, and they had similar baseline characteristics. However, patients admitted to primary centers had significantly higher in-hospital and 7.month mortality, and lower 7.month revascularization rates (Table). Conclusion: Patients admitted to primary care VA hospitals appear to be at increased risk for mortality following ACS. This may be due to under-use of revascularization. since these patients were 31% less likely to be revascularized within 7 months following ACS admission than patients admitted to tertiary hospitals. These results may have important implications for how ACS care and revascularization are delivered in the VA.