Author + information
- Michele Coceani, MD∗∗ (, )
- Gennaro Santoro, MD†,
- Marcello Piacenti, MD‡,
- Umberto Startari, MD‡,
- Bruno Formichi, MD§,
- Cataldo Palmieri, MD‖ and
- Sergio Berti, MD‖
- ∗Invasive Cardiology Unit, Fondazione Toscana G. Monasterio, Pisa, Italy
- †Invasive Cardiology Unit, Careggi Hospital, Florence, Italy
- ‡Arrhythmology Unit, Fondazione Toscana G. Monasterio, Pisa, Italy
- §Anesthesiology Unit, Fondazione Toscana G. Monasterio, Pisa, Italy
- ‖Invasive Cardiology Unit, Fondazione Toscana G. Monasterio, Massa, Italy
- ↵∗Reprint requests and correspondence:
Dr. Michele Coceani, Invasive Cardiology Unit, Fondazione Toscana G. Monasterio, Via Moruzzi 1, 56124 Pisa, Italy.
A 54-year-old man, who had previously undergone 2 radiofrequency catheter ablations of the pulmonary veins for recurrent atrial fibrillation, came to our attention for dyspnea. A chest x-ray showed left pleural effusion and a subsequent computed tomography scan with contrast medium revealed occlusion of both the superior and inferior left pulmonary veins (Figure 1). In addition, a lung perfusion scan demonstrated that the left lung was completely excluded (Figure 2). On the basis of these data, it was decided to attempt to disobstruct the veins percutaneously.
Interatrial transseptal puncture was carried out with a dedicated needle via an 8-F Mullins catheter and obstruction of the 2 left pulmonary arteries was confirmed angiographically (Figure 3, Online Videos 1, 2 and 3). A 6-F Judkins right guiding catheter was then inserted into the Mullins catheter and, after engaging the superior left vein, the occlusion was passed with a 0.014-inch coronary guidewire. Subsequently, angioplasty was performed with sequentially larger balloons (2.5 × 30 mm and 3.5 × 30 mm Sprinter Legend, Medtronic) (Figure 3). Following exchange with a 0.035-inch wire and a 10-F Mullins catheter, the vein was dilated with a 4 × 40 mm Foxcross balloon (Abbott, Abbott Park, Illinois). Finally, an Andrastent 13XL stent (Andramed GmbH, Reutlingen, Germany) was deployed (Figure 3, Online Videos 4 and 5). For the inferior left pulmonary vein, a similar technique was employed, but stenting was performed with a Genesis Opta Pro 7 × 12 mm stent (Cordis Corporation, Miami Lakes, Florida) (Online Videos 4 and 5). At follow-up, the patient’s symptoms improved significantly and a second computed tomography scan showed patency of the two stents (Figure 4). Lung perfusion scan was also repeated and perfusion of the left lung improved significantly (Figure 2).
Pulmonary vein occlusion is a rare complication of catheter ablation and simultaneous occlusion of 2 pulmonary veins is even less common with a reported incidence of roughly 0.3% (1). Clinical presentation may be silent or patients may present with symptoms such as cough, dyspnea, chest pain, and hemoptysis. Various therapeutic strategies have been proposed, ranging from percutaneous intervention to pulmonary lobectomy and surgical repair with pulmonary homograft tissue (2).
For supplemental videos and their legends, please see the online version of this article.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- American College of Cardiology Foundation