Discussion
To the best of our knowledge, this is the first case presentation of pulmonary artery air embolism during pulmonary vein isolation with cryoballoon ablation catheter and acute management of it with pigtail catheter. Embolism of air to the vessel tree may be due to inserting catheters into the circulatory system or may be occurring of atrial-esophageal fistula during and/or after AF ablation.3-5 This is a disastrous complication which can lead to death. The catheters are major reason of air embolism in acute settings. Deep sedation, several catheter exchanges, rapid removal of dilators and catheters, long apne periods with deep breaths, and loosened or air-opened hemostasis valves are conceivable mechanisms of air embolism from inserting catheters due to negative presure and air passage through the catheter into low pressure cardiac chambers.6,7 In this case, the most possible cause of air entry was deep breath and suction of air into catheter while 8F SL1TM (St.Jude Medical) sheath was inserting into the left atrium from right femoral vein. Also, the most likely mechanism of deep breathing is a short period of apnea induced by sedation. The management of the complication was dispersing of bubble by hitting on it with a pigtail catheter. It might cause distal micro embolization of air bubbles. But it was too large for mechanic thrombus aspiration catheter and air aspiration was not applied in our case.8 The clinical symptoms and signs vary according to location of air embolism. If air enters the circulatory system, it forms bubbles occluding vessel and impairs circulation.2 Embolization of air may be treated by several methods, such as 100 % oxygen therapy to maximize end organ damage and reducing the size of air embolus, aspiration of the air or hyperbaric oxygen therapy.3,5,8 A different and exraordinary treatment approach is using pigtail catheter to disperse too large air bubble as our case. Numerous manipulations to prevent air embolism are removal of catheters and dilators slowly, continuous flushing with heparinized saline, avoiding deep sedation, decreasing number of catheter exchanges, reevaluate hemostatic valves, and sheath flushing at slow speeds.