Chest
Volume 126, Issue 2, August 2004, Pages 428-437
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Clinical Investigations
DIFFUSE DISEASES
Decreased Pulmonary Perfusion in Pulmonary Vein Stenosis After Radiofrequency Ablation: Assessment With Dynamic Magnetic Resonance Perfusion Imaging

https://doi.org/10.1378/chest.126.2.428Get rights and content

Study objectives:

The functional impact of pulmonary vein (PV) stenosis on pulmonary perfusion after radiofrequency ablation (RFA) for atrial fibrillation (AF) has not been systematically evaluated previously. Therefore, we correlated magnetic resonance (MR) pulmonary perfusion imaging with single-photon emission CT (SPECT) perfusion and with the degree of PV stenosis (PVS) apparent on MR angiography (MRA) after RF ablation.

Setting:

Joint radiology-cardiology collaborative magnetic resonance unit at the Kerckhoff Heart Center.

Design and patients:

This was a cohort study of 110 patients who were routinely examined by MRA after RFA for AF, whereby 51 patients with a PV diameter reduction of > 25% or with clinical symptoms (ie, dyspnea and cough) were enrolled into the study. Patients were examined at follow-up by MR perfusion imaging and MRA, and the results were compared to those from patients who underwent SPECT scanning and from a control group of 26 untreated patients. Twelve patients underwent PVS dilatation as well as 22 sequential follow-up examinations.

Methods:

Pulmonary perfusion was evaluated using a dynamic contrast-enhanced three-dimensional MR perfusion sequence (1.5 T, 2.5-s temporal resolution, and 0.05 cm spatial resolution), and high-resolution, contrast-enhanced MRA was performed to measure PV diameter. PV dilatation was performed using an angioplasty catheter that was 8 to 10 mm in diameter.

Results:

The localization and extent of perfusion defects measured by MRI or SPECT scanning were precisely matched. MR perfusion imaging detected 20 of 21 perfusion defects (sensitivity, 95.2%; specificity, 100%). PVSs and perfusion deficits correlated closely and showed the following threshold: perfusion decreased substantially in PVs ≤ 6 mm in diameter (21 of 25 areas; 84.0%) compared to 2 of 180 areas (1.1%) with PVs > 6 mm in diameter. After PVS dilatation, perfusion was restored partially after weeks, and complete normalization was seen in 4 of 12 patients (33%).

Conclusions:

PVSs caused severe perfusion deficits, which were reliably demonstrated by MR perfusion imaging. Clinical symptoms correlated better with MR perfusion than they did with MRA. The combination with MRA to assess underlying PVS allowed a “one-stop-shopping” MRI procedure to be carried out. The results led to alterations of RFA techniques, and therefore MRA and MR perfusion imaging may be beneficial in patient follow-up and in evaluating new ablation techniques.

Section snippets

Control Group

First, MR perfusion imaging was evaluated in a control group of 26 patients (mean [± SD] age, 62.3 ± 17.2 years) without any history or suspicion of pulmonary disease or pulmonary perfusion disorder (eg, embolism, pneumonia, malformation, or PVS). Indications for an MR examination in these patients were as follows: an evaluation of left ventricular aneurysm prior to cardiac surgery in 24 patients; and postoperative control after resection of left ventricular aneurysm in 2 patients. The MR

Results

All 51 patients enrolled for PV diameter reduction of > 25% from 110 patients examined after RFA completed the combined MR perfusion/MRA protocol as scheduled. Twelve of these patients developed a severe PVS or clinical symptoms, and therefore underwent PV dilatation and were controlled in 22 follow-up examinations.

MR Perfusion Imaging

MR pulmonary perfusion imaging proved to be reliable for the assessment of pulmonary perfusion, whereby areas of decreased perfusion were precisely matched in both MR perfusion imaging and SPECT perfusion imaging. MR perfusion imaging reached 95.2% sensitivity. Anatomic landmarks in MRI (pulmonary vessels and lobar fissures) and better spatial resolution compared to SPECT scanning eased the diagnosis. A higher contrast between normal and decreased perfusion compared to MRI is inherent to SPECT

Conclusion and Implications

The functional consequences of PVS have been underestimated until now. A combined “one-stop shopping” MRA and MR perfusion examination allowed the visualization of both PVS and subsequent perfusion defects. PVS below a cutoff value of approximately 6 mm invariably resulted in marked and extended perfusion deficits, which led to a reevaluation of the RFA and PV dilatation techniques.

While the mechanism underlying the slow perfusion recovery after PVS dilatation is not understood to date, a

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