CHEST Pulmonary Hemorrhage After Cryoballoon Ablation for Pulmonary Vein Isolation in the Treatment of Atrial Fibrillation Julio Martí-Almor, MD, PhD; Miguel E. Jauregui-Abularach, MD; Begoña Benito, MD; Ermengol Vallès, MD, PhD; Victor Bazan, MD, PhD; Albert Sánchez-Font, MD, PhD; Ivan Vollmer, MD; Carmen Altaba, RN; Miguel A. Guijo, RN; Manel Hervas, RN; and Jordi Bruguera-Cortada, MD
Pulmonary vein isolation has evolved over the past years as an alternative for the treatment of symptomatic recurrences of atrial fibrillation refractory to antiarrhythmic drug treatment. Both radiofrequency energy and cryoballoon ablation have proven useful in this setting. We present the case of a 55-year-old male patient undergoing cryoballoon ablation complicated with pulmonary hemorrhage. The cause of this rare complication may be found in the damage of vascular venous structures near the ablation zone or, alternatively, in hemorrhagic damage of the pulmonary vein surrounding tissue (or less probably to direct injury of the lingular bronchus). The extremely low temperatures achieved in this case (which are often associated with deep balloon position inside the veins) are alarming and should alert the physician about the possibility of an excessively intrapulmonary vein deployment of the cryoablation balloon. CHEST 2014; 145(1):156–157 Abbreviations: LIPV 5 left inferior pulmonary vein
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ryoballoon ablation has become an increasing technique for pulmonary vein isolation in patients with symptomatic paroxysmal atrial fibrillation refractory to antiarrhythmic drug therapy. Acute isolation success has been reported as . 80%.1-3 The procedure is often shorter in duration as Manuscript received March 29, 2013; revision accepted June 6, 2013. Affiliations: From the Electrophysiology Unit, Cardiovascular Department (Drs Martí-Almor, Jauregui-Abularach, Benito, Vallès, Bazan, and Bruguera-Cortada; Ms Altaba; and Messrs Guijo and Hervas), the Respiratory Medicine Department (Dr SánchezFont), and the Radiology-Imaging Department (Dr Vollmer), Hospital del Mar, Barcelona, Spain. Correspondence to: Miguel E. Jauregui-Abularach, MD, Hospital del Mar, Cardiology, Passeig Marítim 25-29, Barcelona, Barcelona, Spain 08003; e-mail: [email protected] © 2014 American College of Chest Physicians. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details. DOI: 10.1378/chest.13-0761 156
Selected Reports
compared with conventional radiofrequency ablation, and the complications rate is similar.1,3,4
Case Report We present the case of a 55-year-old male patient with no relevant past medical history presenting with severely symptomatic atrial fibrillation in the setting of a structurally normal heart refractory to antiarrhythmic treatment. He was admitted for cryoballoon ablation. A magnetic cardiac resonance study showed four independent pulmonary veins: left superior (14 mm in diameter), left inferior (18 mm), right superior (17 mm), and right inferior (17 mm). Oral anticoagulant therapy was withdrawn 3 days prior to the procedure, and enoxaparin was administered at 1 mg/kg subcutaneously bid, the last dose being given 12 h before the procedure. Successful uncomplicated transeptal access was achieved under fluoroscopic and intracardiac echocardiographic guidance. Unfractionated IV heparin was administered to obtain an activating clotting time between 240 and 280 s throughout the procedure. Two cryoballoon applications (300 s each) were delivered to the antrum of each pulmonary vein (Arctic Front; Medtronic CryoCath LP; 28 mm cryoballoon) (Fig 1). The nadir temperatures reached were 2 70°C in the left superior pulmonary vein, 2 73°C in the left inferior pulmonary vein (LIPV), 2 56°C in the right superior pulmonary vein, and 2 48°C in the right inferior pulmonary vein; in the latter, the ablation was stopped prematurely (220 s) due to transient phrenic palsy. Isolation of the four veins was confirmed using a circular mapping catheter. Protamine was administered to reverse heparin effect. Twenty-four hours after the procedure, the patient complained of cough and blood-tinged sputum. A chest CT scan showed a condensation pattern compatible with the diagnosis of pulmonary hemorrhage near the lingular bronchus, in close proximity to the LIPV (Fig 2). A bronchoscopic evaluation
Figure 1. A, Left superior pulmonary vein venogram. B, Left inferior pulmonary vein venogram. Left anterior oblique view. Selected Reports
Figure 2. A, Chest radiograph, left lateral view. Increased volume in the left hilum lower portion (black arrow). B, Chest CT scan with axial reconstruction. A consolidation zone (black arrows) surrounding the left inferior pulmonary vein (LIPV) with ground-glass areas is shown (white arrow), suggesting pulmonary hemorrhage. C, Chest CT scan with modified sagittal reconstruction. Annular consolidation surrounding the LIPV (black arrows) is shown, with adjacent ground-glass areas.
did not demonstrate active bleeding, showing only mucosal petechial instrument-related lesions (Fig 3). During the following days, the cough and blood-tinged sputum ceased, and the patient was discharged. The patient remained asymptomatic during follow-up.
Discussion Pulmonary hemorrhage is a rare but potentially serious complication.1,5,6 In the case we presented here, it appears reasonable to speculate that the cause may be found in the damage of venous structures and/or hemorrhagic damage of the LIPV surrounding tissue or (although less probably) bronchial bleeding related to a direct injury of the lingular bronchus. Extremely low temperatures (as the ones achieved in the left veins) are often associated with deep balloon posi-
tion inside the veins. In this regard, although pulmonary vein isolation is usually achieved at temperatures beyond 2 40°C,1 extremely low temperatures are alarming and should alert the physician about the possibility of an excessively intrapulmonary vein deployment of the balloon (equally important also for avoiding pulmonary vein stenosis with deep balloon inflations). Special care should also be taken when ablating the right veins to avoid right phrenic nerve palsy; continuous phrenic pacing from the superior vena cava is performed to monitor right hemidiaphragm excursions during freezing.
Acknowledgments Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article. Other contributions: CHEST worked with the authors to ensure that the Journal policies on patient consent to report information were met.
References
Figure 3. Bronchoscopy showing the lingular bronchus bifurcation. No active bleeding; the mucosa was intact, showing only petechial instrument-related lesions. journal.publications.chestnet.org
1. Defaye P, Kane A, Chaib A, Jacon P. Efficacy and safety of pulmonary veins isolation by cryoablation for the treatment of paroxysmal and persistent atrial fibrillation. Europace. 2011; 13(6):789-795. 2. Namdar M, Chierchia GB, Westra S, et al. Isolating the pulmonary veins as first-line therapy in patients with lone paroxysmal atrial fibrillation using the cryoballoon. Europace. 2012; 14(2):197-203. 3. Chun KR, Schmidt B, Metzner A, et al. The ‘single big cryoballoon’ technique for acute pulmonary vein isolation in patients with paroxysmal atrial fibrillation: a prospective observational single centre study. Eur Heart J. 2009;30(6):699-709. 4. Chierchia GB, Capulzini L, Droogmans S, et al. Pericardial effusion in atrial fibrillation ablation: a comparison between cryoballoon and radiofrequency pulmonary vein isolation. Europace. 2010;12(3):337-341. 5. Bhagwandien R, Van Belle Y, De Groot N, Jordaens L. Hemoptysis after pulmonary vein isolation with a cryoballoon: an analysis of the potential etiology. J Cardiovasc Electrophysiol. 2011;22(9):1067-1069. 6. van Opstal JM, Timmermans C, Blaauw Y, Pison L. Bronchial erosion and hemoptysis after pulmonary vein isolation by cryoballoon ablation. Heart Rhythm. 2011;8(9):1459. CHEST / 145 / 1 / JANUARY 2014
157
Pulmonary vein isolation has evolved over the past years as an alternative for the treatment of symptomatic recurrences of atrial fibrillation refractory to antiarrhythmic drug treatment. Both radiofrequency energy and cryoballoon ablation have proven useful in this setting. We present the case of a 55-year-old male patient undergoing cryoballoon ablation complicated with pulmonary hemorrhage. The cause of this rare complication may be found in the damage of vascular venous structures near the ablation zone or, alternatively, in hemorrhagic damage of the pulmonary vein surrounding tissue (or less probably to direct injury of the lingular bronchus). The extremely low temperatures achieved in this case (which are often associated with deep balloon position inside the veins) are alarming and should alert the physician about the possibility of an excessively intrapulmonary vein deployment of the cryoablation balloon. CHEST 2014; 145(1):156–157 Abbreviations: LIPV 5 left inferior pulmonary vein
C
ryoballoon ablation has become an increasing technique for pulmonary vein isolation in patients with symptomatic paroxysmal atrial fibrillation refractory to antiarrhythmic drug therapy. Acute isolation success has been reported as . 80%.1-3 The procedure is often shorter in duration as Manuscript received March 29, 2013; revision accepted June 6, 2013. Affiliations: From the Electrophysiology Unit, Cardiovascular Department (Drs Martí-Almor, Jauregui-Abularach, Benito, Vallès, Bazan, and Bruguera-Cortada; Ms Altaba; and Messrs Guijo and Hervas), the Respiratory Medicine Department (Dr SánchezFont), and the Radiology-Imaging Department (Dr Vollmer), Hospital del Mar, Barcelona, Spain. Correspondence to: Miguel E. Jauregui-Abularach, MD, Hospital del Mar, Cardiology, Passeig Marítim 25-29, Barcelona, Barcelona, Spain 08003; e-mail: [email protected] © 2014 American College of Chest Physicians. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details. DOI: 10.1378/chest.13-0761 156
Selected Reports
compared with conventional radiofrequency ablation, and the complications rate is similar.1,3,4
Case Report We present the case of a 55-year-old male patient with no relevant past medical history presenting with severely symptomatic atrial fibrillation in the setting of a structurally normal heart refractory to antiarrhythmic treatment. He was admitted for cryoballoon ablation. A magnetic cardiac resonance study showed four independent pulmonary veins: left superior (14 mm in diameter), left inferior (18 mm), right superior (17 mm), and right inferior (17 mm). Oral anticoagulant therapy was withdrawn 3 days prior to the procedure, and enoxaparin was administered at 1 mg/kg subcutaneously bid, the last dose being given 12 h before the procedure. Successful uncomplicated transeptal access was achieved under fluoroscopic and intracardiac echocardiographic guidance. Unfractionated IV heparin was administered to obtain an activating clotting time between 240 and 280 s throughout the procedure. Two cryoballoon applications (300 s each) were delivered to the antrum of each pulmonary vein (Arctic Front; Medtronic CryoCath LP; 28 mm cryoballoon) (Fig 1). The nadir temperatures reached were 2 70°C in the left superior pulmonary vein, 2 73°C in the left inferior pulmonary vein (LIPV), 2 56°C in the right superior pulmonary vein, and 2 48°C in the right inferior pulmonary vein; in the latter, the ablation was stopped prematurely (220 s) due to transient phrenic palsy. Isolation of the four veins was confirmed using a circular mapping catheter. Protamine was administered to reverse heparin effect. Twenty-four hours after the procedure, the patient complained of cough and blood-tinged sputum. A chest CT scan showed a condensation pattern compatible with the diagnosis of pulmonary hemorrhage near the lingular bronchus, in close proximity to the LIPV (Fig 2). A bronchoscopic evaluation
Figure 1. A, Left superior pulmonary vein venogram. B, Left inferior pulmonary vein venogram. Left anterior oblique view. Selected Reports
Figure 2. A, Chest radiograph, left lateral view. Increased volume in the left hilum lower portion (black arrow). B, Chest CT scan with axial reconstruction. A consolidation zone (black arrows) surrounding the left inferior pulmonary vein (LIPV) with ground-glass areas is shown (white arrow), suggesting pulmonary hemorrhage. C, Chest CT scan with modified sagittal reconstruction. Annular consolidation surrounding the LIPV (black arrows) is shown, with adjacent ground-glass areas.
did not demonstrate active bleeding, showing only mucosal petechial instrument-related lesions (Fig 3). During the following days, the cough and blood-tinged sputum ceased, and the patient was discharged. The patient remained asymptomatic during follow-up.
Discussion Pulmonary hemorrhage is a rare but potentially serious complication.1,5,6 In the case we presented here, it appears reasonable to speculate that the cause may be found in the damage of venous structures and/or hemorrhagic damage of the LIPV surrounding tissue or (although less probably) bronchial bleeding related to a direct injury of the lingular bronchus. Extremely low temperatures (as the ones achieved in the left veins) are often associated with deep balloon posi-
tion inside the veins. In this regard, although pulmonary vein isolation is usually achieved at temperatures beyond 2 40°C,1 extremely low temperatures are alarming and should alert the physician about the possibility of an excessively intrapulmonary vein deployment of the balloon (equally important also for avoiding pulmonary vein stenosis with deep balloon inflations). Special care should also be taken when ablating the right veins to avoid right phrenic nerve palsy; continuous phrenic pacing from the superior vena cava is performed to monitor right hemidiaphragm excursions during freezing.
Acknowledgments Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article. Other contributions: CHEST worked with the authors to ensure that the Journal policies on patient consent to report information were met.
References
Figure 3. Bronchoscopy showing the lingular bronchus bifurcation. No active bleeding; the mucosa was intact, showing only petechial instrument-related lesions. journal.publications.chestnet.org
1. Defaye P, Kane A, Chaib A, Jacon P. Efficacy and safety of pulmonary veins isolation by cryoablation for the treatment of paroxysmal and persistent atrial fibrillation. Europace. 2011; 13(6):789-795. 2. Namdar M, Chierchia GB, Westra S, et al. Isolating the pulmonary veins as first-line therapy in patients with lone paroxysmal atrial fibrillation using the cryoballoon. Europace. 2012; 14(2):197-203. 3. Chun KR, Schmidt B, Metzner A, et al. The ‘single big cryoballoon’ technique for acute pulmonary vein isolation in patients with paroxysmal atrial fibrillation: a prospective observational single centre study. Eur Heart J. 2009;30(6):699-709. 4. Chierchia GB, Capulzini L, Droogmans S, et al. Pericardial effusion in atrial fibrillation ablation: a comparison between cryoballoon and radiofrequency pulmonary vein isolation. Europace. 2010;12(3):337-341. 5. Bhagwandien R, Van Belle Y, De Groot N, Jordaens L. Hemoptysis after pulmonary vein isolation with a cryoballoon: an analysis of the potential etiology. J Cardiovasc Electrophysiol. 2011;22(9):1067-1069. 6. van Opstal JM, Timmermans C, Blaauw Y, Pison L. Bronchial erosion and hemoptysis after pulmonary vein isolation by cryoballoon ablation. Heart Rhythm. 2011;8(9):1459. CHEST / 145 / 1 / JANUARY 2014
157
