Keloid as an Underrecognized Potential Risk Factor for Post-Procedural Pulmonary Vein Stenosis

A 58-year-old man with a keloid (Figure A) underwent pulmonary vein isolation (PVI) using a radiofrequency hot-balloon catheter (SATAKE Hot-Balloon, Toray Industries, Tokyo, Japan). A single energy application with an injected volume of 15 mL (estimated balloon diameter, 30 mm) isolated the right superior pulmonary vein (RSPV; Figure B). Severe pulmonary vein stenosis (PVS) of the RSPV and mild PVS of all other veins developed 9 months following the procedure (Figure C). Pulmonary vein angioplasty (Figure D) was performed and no further progression of the PVS was observed over the next 15-month follow-up period (Figure E).

Figure.

(A) Keloid on the chest. (B) Balloon position during energy application. (C) Severe pulmonary vein stenosis (magnified view) of the right superior pulmonary vein (RSPV) with intimal thickening (white arrows) 9 months following the procedure. (D) Pulmonary vein angioplasty using an 8×20-mm angioplasty balloon. (E) Follow-up computed tomography 15 months following balloon angioplasty. AP, anterior-posterior; LA, left atrium.

Hyperreaction of fibrosis and neointimal proliferation are potential mechanisms for PVS, which can be severe and multifocal.¹ Similar to the association between higher in-stent restenosis in patients with keloid,² there may be a possible association between keloids and post-procedural PVS, thus close surveillance may be needed after PVI regardless of the energy source. Of note, forward pressure may push the hot-balloon into the PV ostium, thus potentially increasing the risk of PVS.

Disclosure

H.Y. received a consultant fee; K.A. belongs to the endowed department of Toray Industries. The other authors declare no conflicts of interest.

References

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