Ablation of atrial arrhythmias after lobectomy: high-density mapping and CT integration to guide individualized treatment

Atrial fibrillation is a known complication following thoracic surgery, with residual pulmonary vein (PV) stumps often implicated as sources of arrhythmogenic triggers. Existing literature suggests that these stumps can maintain ectopic activity, leading to arrhythmia recurrence. In this case, contrary to common findings, a PV stump in a post-lobectomy patient was found to be electrically inert, challenging the assumption that all such stumps are pro-arrhythmic. The absence of electrical activity in the stump suggests that its anatomical characteristics, such as being extremely short and even flat, may prevent it from acting as a trigger for atrial fibrillation. A 64-year-old male with a history of right superior bilobectomy for a carcinoid tumor presented with symptomatic atrial flutter and paroxysmal atrial fibrillation. His medical history was significant for severe left ventricular dysfunction (Ejection Fraction, EF 25%), hypertension, and obesity. After confirming the absence of left atrial thrombus, he underwent a successful radiofrequency catheter ablation of the cavo-tricuspid isthmus (CTI), which terminated the atrial flutter. Subsequently, electroanatomic mapping of the left atrium was performed. Despite the history of lobectomy, mapping revealed no electrical activity originating from the right superior pulmonary vein stump. The remaining PVs were successfully isolated using radiofrequency energy. The patient remained in stable sinus rhythm without antiarrhythmic drugs at his 6-month follow-up. This case demonstrates that a PV stump after lobectomy is not universally arrhythmogenic. The absence of electrical activity in the stump suggests that its anatomical characteristics, such as being extremely short, may prevent it from acting as a trigger for atrial fibrillation. This report suggests the potential value of detailed, individualized electroanatomic mapping in post-lobectomy patients before considering stump ablation. This patient-specific approach can help avoid unnecessary ablations, thereby minimizing procedural risks while ensuring that only clinically significant arrhythmogenic substrates are targeted. Not applicable.