Pulsed-Field Redo Ablation With Balloon Angioplasty for Postablation Pulmonary Vein Stenosis

Pulmonary vein stenosis (PVS) is a serious complication of atrial fibrillation (AF) ablation, occurring in approximately 1% to 3% of cases. For patients with PVS as a complication of AF ablation and recurrence of AF, repeat radiofrequency or cryoablation may exacerbate stenosis or even lead to pulmonary vein occlusion. Pulsed-field ablation (PFA), a novel nonthermal energy modality, offers better tissue selectivity and less proliferative effects and may be suitable for redo ablation in patients with PVS and recurrent AF.

A 39-year-old woman presented with persistent cough for 3 months after radiofrequency ablation for paroxysmal AF. Transthoracic echocardiography revealed accelerated left pulmonary vein flow (1.3 m/s), and angiography confirmed moderate stenosis (left superior pulmonary vein: 70%, left inferior pulmonary vein: 60%). Owing to AF recurrence refractory to medical treatment, we performed pulmonary vein reisolation using PFA combined with drug-coated balloon angioplasty for the PVS. Postprocedurally, the pressure gradient across the pulmonary veins improved significantly, with intracardiac echocardiography demonstrating normalized flow velocity. Immediate angiography and subsequent computed tomography angiography confirmed resolution of stenosis, and the patient maintained sinus rhythm.

PFA with concurrent drug-coated balloon angioplasty can be safe and effective in select cases of patients with both PVS after AF ablation and recurrent AF refractory to drug therapy.