A 43-year-old man developed hemoptysis due to left pulmonic vein stenosis and occlusion following radiofrequency ablation, which was successfully managed with balloon angioplasty and stenting.
Case Report (n=1)
This case highlights the importance of recognizing pulmonary vein stenosis as a rare but significant cause of post-ablative hemoptysis and managing it with multidisciplinary care including angioplasty and stenting.
Abstract Introduction Atrial fibrillation is increasingly treated with catheter ablation, which can result in rare complications including pulmonary vein stenosis and occlusion. We present a case of post-ablative pulmonary vein stenosis and occlusion presenting as hemoptysis. Case Presentation A 43-year-old man with refractory atrial fibrillation on anticoagulation and tachycardia-mediated cardiomyopathy was admitted for acute hemoptysis. He was hemodynamically stable with normal hemoglobin. Computed tomography demonstrated left upper lobe (LUL) consolidative and ground glass opacities, a left hilar soft tissue mass, left inferior pulmonic vein stenosis, and left superior pulmonic vein occlusion. One month prior, he underwent wide-area circumferential radiofrequency ablation complicated by pericarditis and treated with colchicine and ibuprofen. He had also previously undergone pulmonary vein isolation ablation without success. Preprocedural mapping for both ablations demonstrated left pulmonic vein stenosis with an enlarged right pulmonic vein. Pulmonology and Cardiology were consulted to discuss hilar biopsy, anticoagulation use, and pulmonic vein angioplasty. Anticoagulation was held temporarily, and bronchoscopy with endobronchial ultrasound revealed a left hilar hematoma with collateral vessel burden and slow oozing from the distal left mainstem bronchus, seemingly supplied by these collaterals. This was controlled with topical agents. He was discharged and later underwent left superior pulmonic vein balloon angioplasty and left inferior pulmonic vein stenting. Interval imaging demonstrated improvement in the left hilar mass and LUL airspace disease. He remains in normal sinus rhythm. Discussion Hemoptysis following ablation occurs in approximately 3% of patients, and over 75% of cases are mild, resolving without intervention.1 However, a significant cause of post-ablative hemoptysis is pulmonary vein stenosis (PVS) with an incidence of 0.29% per year.2 Nonspecific symptoms, variable onset, and lack of post-procedural surveillance imaging render diagnosis challenging.2 Untreated PVS can progress to pulmonary infarctions and pulmonary hypertension. Balloon angioplasty and stenting remain the gold standards for management. In this patient’s case, his presumed congenital left pulmonic vein stenosis increased his risk of procedural complication. Repeat instrumentation, collateral vessel formation, nonsteroidal anti-inflammatory use, and chronic anticoagulation use also contributed to his condition. This case emphasized the importance of recognizing complications, performing targeted work-up, and coordinating multidisciplinary care. References 1. Kumar N, Ranganathan MK, Mustafa S, Saraf K, Timmermans C, Gupta D. Hemoptysis After Cryoablation for Atrial Fibrillation. J Atr Fibrillation. 2019;12(4):2237. 2. Cappato R, Calkins H, Chen SA, et al. Updated worldwide survey on the methods, efficacy, and safety of catheter ablation for human atrial fibrillation. Circ Arrhythm Electrophysiol. 2010;3(1):32-38. This abstract is funded by: none
Whittaker et al. (Fri,) conducted a case report in Post-ablative pulmonary vein stenosis and occlusion (n=1). Balloon angioplasty and stenting was evaluated. A 43-year-old man developed hemoptysis due to left pulmonic vein stenosis and occlusion following radiofrequency ablation, which was successfully managed with balloon angioplasty and stenting.