Spontaneous massive hemothorax presenting as a ...

Cite this article as: Obeso A, Tilve A, Jimenez A, Bonatti J. Spontaneous massive hemothorax presenting as a late complication of stent implantation in a patient with pulmonary vein stenosis following radiofrequency ablation for atrial fibrillation. Interact CardioVasc Thorac Surg 2018; doi:10.1093/icvts/ivx380.

Spontaneous massive hemothorax presenting as a late complication of stent implantation in a patient with pulmonary vein stenosis following radiofrequency ablation for atrial fibrillation Andres Obesoa,*, Amara Tilveb, Alejandro Jimeneza and Johannes Bonattia a b

Heart and Vascular Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates Department of Radiology, Alvaro Cunqueiro Hospital, Vigo, Spain

* Corresponding author. Heart and Vascular Institute, Cleveland Clinic Abu Dhabi, Al-Maryah Island, Abu Dhabi, United Arab Emirates. Tel: +97125019000 (ext: 49014); e-mail: [email protected] (A. Obeso). Received 19 July 2017; received in revised form 12 October 2017; accepted 1 November 2017

Abstract Catheter ablation for symptomatic and drug-resistant atrial fibrillation is considered as the main acquired cause of pulmonary vein stenosis in adults. Controversy currently exists about the optimal treatment approach of this entity. Stenting seems to achieve lower vessel restenosis rates than isolated balloon angioplasty. However, these techniques are not exempt from complications. We present a case of spontaneous massive haemothorax presenting as a late complication of stent implantation in a patient with pulmonary vein stenosis. Keywords: Atrial fibrillation • Catheter ablation • Haemothorax • Stents

INTRODUCTION Catheter ablation (CA) for recurrent, symptomatic and drug-resistant atrial fibrillation is the most common cause of pulmonary vein (PV) stenosis in adults. Ablation-induced PV narrowing remains a challenge for physicians in terms of diagnosis and management. Early detection is essential for prompt treatment and to improve clinical outcomes. Stenting seems to achieve lower vessel restenosis rates than isolated balloon angioplasty [1]. However, in spite of their relative safety, these techniques are not exempt from complications. We present a case report of spontaneous massive haemothorax after stent implantation in a patient with ablation-induced PV stenosis.

CASE REPORT A 55-year-old man who underwent cryoballoon CA (PV isolation) and radiofrequency CA of the cavotricuspid isthmus 1 year prior for paroxysmal atrial fibrillation which failed to respond to antiarrhythmic drugs. The ablation procedure was uneventful with acute periprocedural success. Nine months postablation, the patient began to experience sudden pleuritic left chest pain accompanied by dyspnoea at rest. He was initially managed conservatively with analgesics, but after recurrent visits to the emergency department, a thoracic computed tomography scan (Fig. 1A) revealed severe left lower PV stenosis associated with bilateral thickening of the peribronchovascular interstitium, especially striking at the level of the left lower lobe. Given these findings, a stent (Express StentV R

8 17 mm) was successfully placed into the left lower PV, from its ostium to the first bifurcation distally, with excellent acute results (Fig. 1B). After an uneventful recovery without any complications, the patient was discharged with dual antiplatelet therapy (clopidogrel 75 mg and aspirin 100 mg). One month after the procedure, the patient returned to the hospital complaining of pleuritic chest pain and dyspnoea at rest. On physical examination, he had low blood oxygen saturation levels and had cool and pale skin. Serial standard laboratory tests demonstrated progressive anaemia requiring blood transfusion. Chest X-ray (Fig. 1C) revealed a diffuse opacification of the left hemithorax prompting a chest computed tomography scan. The latter (Fig. 1D) showed a massive left pleural effusion that shifted the mediastinum to the opposite side. Haemothorax was confirmed by diagnostic thoracentesis (pleural haematocrit 28.8%). Finally, the patient underwent a left thoracotomy. 2600 ml of hematic pleural effusion were evacuated from the pleural cavity. The intensive pulmonary hilar fibrosis prevented the exploration of the left lower PV, and no bleeding point was identified. Postoperative course was favourable, and the patient was discharged on the 10th postoperative day. A follow-up computed tomography scan showed that the stent remained patent and well positioned (Fig. 1E and F).

COMMENT Percutaneous interventional procedures are considered the mainstay of treatment for patients with highly symptomatic PV stenosis after CA for atrial fibrillation. However, neither venoplasty nor

C The Author 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. V

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CASE REPORT

CASE REPORT

Interactive CardioVascular and Thoracic Surgery (2018) 1–4 doi:10.1093/icvts/ivx380

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Figure 1: (A) Severe left lower pulmonary vein (PV) stenosis (white arrow). (B) Stent placed into the left lower PV. The patency of the stent is clearly shown. (C) Complete opacification of the left hemithorax. (D) Massive left pleural effusion and ipsilateral pulmonary collapse. (E) 3D reconstruction of left atrium and PVs. Stent is in place. (F) Postoperative computed tomography scan demonstrating that the stent remained patent and well positioned.

stenting is exempt from possible perioperative complications. In accordance with the largest series reported, overall complication rates range from 0% to 25% (Table 1). Embolic phenomena must be taken into account after balloon dilation and stenting of PV stenosis.

Qureshi et al. [2] reported a patient with magnetic resonance imaging evidence of middle cerebral artery distribution stroke after PV stenting. In the same way, an embolus lodged at the iliac artery was described by Packer et al. [3]. Other adverse events were also


A. Obeso et al. / Interactive CardioVascular and Thoracic Surgery

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Author (year)

Patients Affected Percutaneous Venoplasty Stent ± Perioperative Type of (n) PVs (n) interventional venoplasty complications, complications procedures (n) n (%)

Fender et al. [1]

113

178

178

92

86

20 (16.8)

• • • • • • •

Qureshi et al. [2]

17

30

30

25

5

4 (23.5)

• •

Packer et al. [3]

23

34

34

20

14

4 (17.3)

• • • •

• • Prieto et al. [5]

44

80

55

39

16

3 (6.8)

• •

Neumann et al. [6]

12

15

15

15

0

•

3 (25)

• • Saad et al. [7]

18

Di Biase et al. [4]

18

24

6

7

Pu¨rerfellner et al. [8]

Haemoptysis PV perforation Tamponade Dislodged stent Pleural effusion Pericardial effusion ST-segment elevation Haemoptysis Pulmonary haemorrhage Pulmonary vein tear Embolism (brain) Hypotension and ST elevation Peripheral PV guidewire perforation with bleeding Acute haemothorax Embolism (iliac artery) Transient neurological deficit Two patients with pulmonary vein tear resulting in cardiac tamponade Allergic reaction to the contrast agent Haemoptysis Slight dissection of pulmonary vein Pulmonary vein perforation

Bleeding treatment

Follow-up (months), median (range)

Sternotomy 55.2 Pericardiocentesis Airway control

Emergent surgical repair

10.7 (0.5–23)

Intubation, ventilation, chest tube

18 (3–34)

Evacuation of pericardial space

25 (4–46)

Covering the distal vein with a stent

12

8

1 (5.5)

•

15

7

8

1 (5.5)

• Cardiac perforation NA

6

4

2

0 (0)

Open heart surgery

47.7 (47.2–48.5)

NA 14 8 (6–10)

NA: not available; PVs: pulmonary veins.

reported such as haemoptysis, pulmonary haemorrhage and transient neurological deficit [1, 2]. Nevertheless, bleeding complications represent the most frequent and serious cause of morbidity after venoplasty and stenting of PV stenosis. Most vascular accidents, which are mainly caused by an injury at the PV, lead to cardiac tamponade or haemothorax requiring urgent surgical treatment [1, 2– 4]. These vascular complications are usually acute events. Our case is extremely infrequent due to the late presentation, and the pathophysiology is still unclear. A possible theory may be that a small PV tear caused by the stent placement or the pre-stent balloon angioplasty slowly progressed to rupture. Additionally, pulmonary hilar fibrosis might facilitate this process.

complications of these interventional procedures. Such bleeding complications can be life-threatening. Therefore, a close postoperative follow-up is advisable even beyond 6 months after stenting. Conflict of interest: none declared.

REFERENCES [1]

[2]

CONCLUSION In conclusion, electrophysiologists, invasive cardiologist/radiologist and surgeons must be aware of the potentially dangerous

[3]

Fender EA, Widmer RJ, Hodge DO, Cooper GM, Monahan KH, Peterson LA et al. Severe pulmonary vein stenosis resulting from ablation for atrial fibrillation. Presentation, management, and clinical outcomes. Circulation 2016;134:1812–21. Qureshi AM, Prieto LR, Latson LA, Lane GK, Mesia CI, Radvansky P. Transcatheter angioplasty for acquired pulmonary vein stenosis after radiofrequency ablation. Circulation 2003;108:1336. Packer DL, Keelan P, Munger TM, Breen JF, Asirvatham S, Peterson LA. Clinical presentation, investigation, and management of pulmonary vein stenosis complicating ablation for atrial fibrillation. Circulation 2005;111:546.


CASE REPORT

Table 1: Review of the literature

4 [4]

[5]

[6]

A. Obeso et al. / Interactive CardioVascular and Thoracic Surgery Di Biase L, Fahmy TS, Wazni OM, Bai R, Patel D, Lakkireddy D. Pulmonary vein total occlusion following catheter ablation for atrial fibrillation: clinical implications after long-term follow-up. J Am Coll Cardiol 2006;48:2493–9. Prieto LR, Schoenhagen P, Arruda MJ, Natale A, Worley SE. Comparison of stent versus balloon angioplasty for pulmonary vein stenosis complicating pulmonary vein isolation. Journal of Cardiovascular Electrophysiology 2008;19:673–678. Neumann T, Kuniss M, Conradi G, Sperzel J, Berkowitsch A, Zaltsberg S et al. Pulmonary vein stenting for the treatment of acquired severe

[7]

[8]

pulmonary vein stenosis after pulmonary vein isolation: clinical implications after long-term follow-up of 4 years. Journal of Cardiovascular Electrophysiology 2009;20:251–257. Saad EB, Marrouche NF, Saad CP, Ha E, Bash D, White RD et al. Pulmonary Vein Stenosis after Catheter Ablation of Atrial Fibrillation:Emergence of a New Clinical Syndrome. Ann Intern Med. 2003;138:634–8. Pu¨rerfellner H, Aichinger J, Martinek M, Nesser HJ, Cihal R, Gschwendtner M et al. Incidence, management, and outcome in significant pulmonary vein stenosis complicating ablation for atrial fibrillation. Am J Cardiol 2004;93:1428–31.
