Haemoptysis as Complication of Wire-Guided Pulmonary Vein Orifice Cryoballoon Ablation in Complex Anatomy: a Clinical Case Series

Background. Cryoballoon ablation of pulmonary vein orifices is an effective measure in atrial fibrillation but associates with risks of interventional complications, including haemoptysis. The described clinical case series presents novel evidence to revisit the complication sources.

Materials and methods. Four haemoptysis-complicated cryoballoon ablations of pulmonary vein orifice have been analysed retrospectively. Interventions completed in a common clinical protocol with no additional postoperative complications.

Results. Fluoroscopy revealed a loop-formed balloon-supporting end of guidewire located in peripheral lower lobe of right lung. Postoperative chest computed tomography also depicted the main lung blood volume confined in right lower lobe, thus indicating pulmonary damage by the guidewire.

Discussion. Pulmonary vein anatomy is diverse and can greatly sophisticate the cryoballoon ablation procedure with a peculiar balloon navigation in left atrium. An optimal pulmonary vein orifice occlusion can be attained with guidewire, albeit incurring complications in form of haemoptysis.

Conclusions. The appliance advancement towards lung periphery associates with a higher risk of haemoptysis and bleeding. Perioperative haemoptysis and bleeding are most likely associated with mechanical injury to minor veins and require further investigation.

1. Hoffmann E., Straube F., Wegscheider K., Kuniss M., Andresen D., Wu L.Q., et al. Outcomes of cryoballoon or radiofrequency ablation in symptomatic paroxysmal or persistent atrial fibrillation. Europace. 2019;21(9):1313–24. DOI: 10.1093/europace/euz155.

2. Miyazaki S., Tada H. Complications of cryoballoon pulmonary vein isolation. Arrhythm Electrophysiol Rev. 2019;8(1):60–4. DOI: 10.15420/aer.2018.72.2

3. Kuwahara T., Takahashi A., Takahashi Y., Kobori A., Miyazaki S., Takei A., et al. Clinical characteristics of massive air embolism complicating left atrial ablation of atrial fibrillation: lessons from five cases. Europace. 2012;14(2):204–8. DOI: 10.1093/europace/eur314

4. Ströker E., de Asmundis C., Kupics K., Takarada K., Mugnai G., De Cocker J., et al. Value of ultrasound for access guidance and detection of subclinical vascular complications in the setting of atrial fibrillation cryoballoon ablation. Europace. 2019;21(3):434–9. DOI: 10.1093/europace/euy154

5. Calkins H., Hindricks G., Cappato R., Kim Y.H., Saad E.B., Aguinaga L., et al. 2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation: Executive summary. Europace. 2018;20(1):157–208. DOI: 10.1093/europace/eux275

6. Aksu T., EbruGolcuk S., Yalin K. Haemoptysis and pulmonary haemorrhage associated with cryoballoon ablation. Europace. 2015;17(8):1240. DOI: 10.1093/europace/euu407

7. Yoshizawa R., Owada S., Sawa Y., Deguchi H. Successful removal of a circular mapping catheter which perforated the pulmonary vein during cryoballoon ablation by lateral thoracotomy: a case report. Eur Heart J Case Rep. 2020;4(4):1–5. DOI: 10.1093/ehjcr/ytaa140

8. Andrade J.G., Cheung C.C., Deyell M.W. Hemoptysis and cryoballoon ablation: is it crystal clear? JACC Clin Electrophysiol. 2020;6(7):783–5. DOI: 10.1016/j.jacep.2020.05.033

9. Fukunaga H., Higuchi R., Tanizaki K., Isobe M. Pulmonary vein perforation into bronchi: a rare but life-threatening complication of cryoballoon ablation. Eur Heart J Case Rep. 2019;3(1):ytz022. DOI: 10.1093/ehjcr/ytz022

10. Schweigert M., Almeida A.B. Life-threatening pulmonary haemorrhage during cryoballoon ablation for atrial fibrillation. Eur J Cardiothorac Surg. 2018;54(4):789–91. DOI: 10.1093/ejcts/ezy160

11. Rosu R., Cismaru G., Muresan L., Puiu M., Gusetu G., Istratoaie S., et al. Intracardiac echocardiography for transseptal puncture. A guide for cardiac electrophysiologists. Med Ultrason. 2019;21(2):183–90. DOI: 10.11152/mu-1827

12. Miyazaki S., Nakamura H., Taniguchi H., Takagi T., Iwasawa J., Watanabe T., et al. Esophagus-related complications during second-generation cryoballoon ablation-insight from simultaneous esophageal temperature monitoring from 2 esophageal probes. J Cardiovasc Electrophysiol. 2016;27(9):1038–44. DOI: 10.1111/jce.13015

13. Ghosh J., Sepahpour A., Chan K.H., Singarayar S., McGuire M.A. Immediate balloon deflation for prevention of persistent phrenic nerve palsy during pulmonary vein isolation by balloon cryoablation. Heart Rhythm. 2013;10(5):646–52. DOI: 10.1016/j.hrthm.2013.01.011

14. Aryana A., Kenigsberg D.N., Kowalski M., Koo C.H., Lim H.W., O’Neill P.G., et al. Verification of a novel atrial fibrillation cryoablation dosing algorithm guided by time-to-pulmonary vein isolation: Results from the Cryo-DOSING Study (Cryoballoon-ablation DOSING Based on the Assessment of Time-to-Effect and Pulmonary Vein Isolation Guidance). Heart Rhythm. 2017;14(9):1319–25. DOI: 10.1016/j.hrthm.2017.06.020

15. Iacopino S., Mugnai G., Takarada K., Paparella G., Ströker E., De Regibus V., et al. Second-generation cryoballoon ablation without the use of real-time recordings: A novel strategy based on a temperature-guided approach to ablation. Heart Rhythm. 2017;14(3):322–8. DOI: 10.1016/j.hrthm.2016.11.023

16. Okano T., Okada A., Tabata H., Kobayashi H., Shoin W., Yoshie K., et al. Wire perforation causing cardiopulmonary arrest during radiofrequency hot balloon ablation for pulmonary vein isolation. J Cardiol Cases. 2019;19(5):169–72. DOI: 10.1016/j.jccase.2019.01.001

17. Aryana A., Baker J.H., Espinosa Ginic M.A., Pujara D.K., Bowers M.R., O’Neill P.G., et al. Posterior wall isolation using the cryoballoon in conjunction with pulmonary vein ablation is superior to pulmonary vein isolation alone in patients with persistent atrial fibrillation: A multicenter experience. Heart Rhythm. 2018;15(8):1121–9. DOI: 10.1016/j.hrthm.2018.05.014

18. Kandathil A., Chamarthy M. Pulmonary vascular anatomy & anatomical variants. Cardiovasc Diagn Ther. 2018;8(3):201–7. DOI: 10.21037/cdt.2018.01.04

19. The Human Protein Atlas [Internet]. Stockholm. From 2005. [cited 2021 June 8]. Available from: https://v15.proteinatlas.org/learn/dictionary/normal/lung+1