Pulmonary vein perforation causing life-threatening pulmonary hemorrhage during pulsed field ablation for atrial fibrillation using a J-shaped radiofrequency transseptal puncture wire

Figures

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  Figure 1. Fluoroscopic images during atrial septal puncture using radiofrequency transseptal wire. A: Under intracardiac echocardiographic guidance, a transseptal puncture was performed, and the wire was advanced into the left atrium, maintaining its J shape and reaching the LSPV. The LSPV superior branch, LSPV inferior branch, and LIPV are outlined by blue lines, and the atrial septum is indicated by the blue dotted line. B: During sheath advancement into the left atrium, the wire tip unintentionally entered an inferior branch of the LSPV, leading to straightening of the J-shaped tip (green triangle). C: Further sheath advancement (orange arrow) transmits forward force along the wire, partially straightening the V-shaped venous segment and allowing the wire tip to advance into a more distal pulmonary venous branch (green arrow). LIPV = left inferior pulmonary vein; LSPV = left superior pulmonary vein.

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  Figure 2. Postprocedural CT and bronchoscopic findings. A: Contrast-enhanced CT showing contrast extravasation (red circle) from the distal left superior pulmonary vein inferior branch, indicating a bleeding site. B: Noncontrast CT (lung window) demonstrating consolidation in the left upper lobe (red circle) corresponding to the bleeding site and bilateral lower lobe infiltrates (blue circles), consistent with blood aspiration. C: Bronchoscopy confirming active bleeding from the left upper-lobe bronchus. D: Follow-up contrast-enhanced CT performed the next day shows complete extravasation resolution (red dotted circle). CT = computed tomography.

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  Figure 3. Neuroimaging and electrocardiographic findings after pulmonary vein injury. A: Brain magnetic resonance imaging on postoperative day 14. The upper panel shows a fluid-attenuated inversion recovery image, and the lower panel shows the corresponding diffusion-weighted image, both demonstrating scattered high-signal lesions in the left frontal, parietal, and temporal lobes. B: 12-lead electrocardiogram demonstrating transient ST-segment elevation in leads II, III, and aVF during hemorrhagic shock (upper panel), which resolved promptly after hemodynamic stabilization (lower panel).

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  Figure 4. Mechanism of pulmonary vein perforation caused by a J-shaped RF transseptal wire. A:Left: Photograph of a J-shaped RF transseptal wire with a 7-mm straight distal section that allows RF energy delivery from the tip. The distal tip is relatively stiff compared with the proximal shaft (red dotted circle). Once advanced into the left atrium, the wire forms a J-tip shape designed to minimize the risk of tissue injury. Right: Schematic illustration of a J-shaped RF transseptal wire showing its distal curved configuration, which helps prevent excessive advancement into peripheral vessels. B: Schematic illustration showing how a J-shaped wire may inadvertently advance deeper within a V-shaped pulmonary vein, depicted sequentially. Left: The wire advances within the vein while maintaining its J shape in a V-shaped venous configuration. Center: Engagement at the angulated segment causes the J-shaped tip to straighten. Right: Continued forward force (orange arrow) is transmitted along the wire shaft (green arrow), partially straightening and elongating the V-shaped venous segment. As resistance decreases, the wire advances further into a distal branch, where the relatively stiff distal tip…

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  Supplementary Figure.