Percutaneous treatment of pulmonary vein stenosis: a transesophageal echocardiography step-by-step guide in diagnosis and treatment

Abstract Background Acquired severe pulmonary vein stenosis (PVS) is a rare but clinically relevant complication of radiofrequency catheter ablation for atrial fibrillation. Diagnosis is often delayed or missed without a multimodality imaging approach. Once established, percutaneous intervention with balloon angioplasty or pulmonary vein stent implantation represents the preferred therapeutic strategy. Imaging plays a central role in determining the indication for intervention, assessing the severity and extent of disease, and accurately localizing the stenosis, thereby enabling appropriate procedural planning. Aim This practical review provides a comprehensive overview of the role of multimodality imaging in patients with suspected PVS and proposes an integrated workflow for diagnosis, treatment, and follow-up. In addition, it offers a step-by-step illustrated guide to the use of transoesophageal echocardiography during percutaneous intervention, addressing the current lack of standardized protocols. The review is structured to cover diagnostic pathways, procedural guidance, and post-intervention surveillance.