Pulmonary Lobectomy for Chronic Pulmonary Vein Occlusion after Catheter Ablation for Atrial Fibrillation: A Case Report and Literature Review.

Abstract

Introduction: Pulmonary vein stenosis (PVS) is known as one of the chronic complications after catheter ablation for atrial fibrillation (AF). The endovascular approach is a less invasive treatment option for PVS, while pulmonary lobectomy is also chosen, especially for patients with pulmonary vein occlusion. Here, we present a case of pulmonary vein occlusion accompanied by pulmonary necrosis that was successfully treated by pulmonary lobectomy.

Case presentation: A 65-year-old man underwent catheter ablation for AF along with administration of anticoagulants at his previous hospital. After treatment for 6 months, hemoptysis appeared, and chest computed tomography (CT) showed an infiltration shadow in the lower lobe of the left lung. The patient was admitted to the hospital, and antibiotic therapy was initiated. Despite 10 days of antibiotic therapy, there was no improvement, and the lung infiltration worsened. Therefore, on the 10th day of hospitalization, the patient was transferred to our institute. A bloody lavage fluid was obtained under a bronchoalveolar lavage, suggesting alveolar hemorrhage. Then, a contrast-enhanced chest CT scan confirmed a complete occlusion of the left inferior pulmonary vein with suspicion of pulmonary necrosis. We performed a left lower lobectomy under a video-assisted thoracic approach. The lower lobe of the left lung was dark red with a bad smell, and there was 500-ml bloody pleural fluid. Intraoperative transesophageal echocardiography showed no thrombus in the inferior pulmonary vein. The surrounding tissue of the occlusion area of pulmonary vein was sclerotic and inflammatory with firm adhesions to the vagus nerve. The inferior pulmonary vein was separated on the non-hardening peripheral side of the occlusion point using a stapler. Pathological examination confirmed multiple hemorrhagic infarctions in the parenchyma. The patient was discharged on the 8th postoperative day, and there was no recurrence of hemoptysis at 6 months postoperatively.

Conclusions: We successfully treated patients with pulmonary vein occlusion following catheter ablation through pulmonary lobectomy. While endovascular treatment is less invasive and remains the first choice for PVS, lobectomy should be considered in patients with complete occlusion, especially when accompanied by pulmonary necrosis, or in recurrent patients after endovascular treatment.