Pulmonary Vein Perforation and Life-Threatening Hemoptysis During Cryoballoon Ablation for Persistent Atrial Fibrillation

Figures

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  Figure 1. Right Inferior Pulmonary Vein Angiography (A) Post-first right inferior pulmonary vein angiography with complete cryoballoon occlusion. The contrast medium showed unnatural accumulation (red dotted circle). (B) After insertion of the circular mapping catheter into the right inferior pulmonary vein again, complete occlusion can be observed on the second angiography, and hemoptysis occurred subsequently. The contrast medium regurgitated into the bronchi (red arrows).

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  Figure 2. After Intubation Using a Double-Lumen Tube (A) After intubation using a double-lumen tube (white arrows) and a bronchial blocker (red arrows) to the right lower lobe of the bronchial lumen. (B) Contrast medium regurgitation into the lower bronchi stopped caused by bronchial blocker obstruction (blue arrows); however, leakage of the contrast medium into the lung persisted.

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  Figure 3. Computed Tomography Angiography Computed tomography angiography shows contrast medium leakage into the right lower lobe within the red dotted circle. (A) Axial view, (B) frontal view.

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  Figure 4. 3-Dimensional Computed Tomography (A) Three-dimensional computed tomography angiography of the pulmonary veins before cryoballoon ablation demonstrates an uncommon right inferior pulmonary vein (RIPV) anatomy that immediately branches into 3 thin branches. Red arrows indicate the upper branch. (B) Three-dimensional computed tomography angiography of the pulmonary veins after cryoballoon ablation; contrast medium leakage is indicated by the green area, and the small upper RIPV branch was injured by the circular mapping catheter.

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  Figure 5. Right Lower Lobe With Intrapulmonary Hematoma (A) Right-sided view, (B) inside view.

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  Figure 6. Microscopic Image With Elastica van Gieson Staining Magnification of the right inferior pulmonary vein, which was injured by the circular mapping catheter. This image shows the pulmonary vein wall (white arrows) and ruptured pulmonary vein (white dotted arrows). The hemorrhage invaded the perivenous pulmonary tissue.