Atrial fibrillation ablation in patients with pulmonary lobectomy or pneumectomy: Procedural challenges and efficacy

Background: Catheter ablation of atrial fibrillation (AF) in patients with pulmonary lobectomy or pneumectomy is challenging due to anatomical alterations. After lung resection, electrically active pulmonary vein (PV) stumps remain and need to be localized for PV isolation (PVI). The present study aims to describe clinical challenges of PVI in patients with pulmonary lobectomy or pneumectomy. Methods: We performed a retrospective study on 19 patients with previous pulmonary lobectomy or pneumectomy undergoing catheter ablation for AF in three German hospitals. Results: Nineteen patients with paroxysmal, persistent, or longstanding-persistent AF and history of pulmonary lobectomy (n = 11) or pneumectomy (n = 8) were enrolled. Catheter ablation was performed as radiofrequency (RF) ablation using 3D mapping, robotic RF ablation, or by using balloon devices. Decent anatomical changes were observed in patients with lobectomy while cardiac rotation and mediastinal shifting was dominant in patients with pneumectomy. Visualization of all PVs including PV stumps by PV angiography was possible in 10 of 19 patients (52.6%). PV spikes were observed in all identified PV remnants. In nine patients (47.4%), at least one PV remnant could not be identified and electrical isolation was not performed. During 24 months follow-up, patients with incomplete PVI had a significantly shorter arrhythmia-free survival than patients with complete PVI (76.2% [95% Confidence interval (CI) 47.2-100.0%] vs 40.0% [95% CI 5.6-74.1%], P =.043). Conclusion: In patients with AF and previous lobectomy or pneumectomy, identification and isolation of all PVs are challenging but crucial for ablation success. Additional imaging techniques may be necessary to achieve complete PVI.