Case Report
A 50 year old man with paroxysmal AF was admitted to our hospital for AF
cryoballoon ablation. Electric cardioversion was done two times with
medical treatment including propafenone and amiodarone for one year. AF
attacks were resistant all therapies. His body mass index was 32
kg/m2. Further he had history of hypertension for 5
years. Medical treatment was ramipril 5 mg once a day, rivaroxaban 20 mg
once a day and propafenone 150 mg twice a day. The patient was taken to
electrophsiology laboratory after informed consent. The procedure was
started under conscious sedation with midazolam. 6F and 8F sheaths were
placed into right femoral vein. Also, 6F sheath was inserted into left
femoral artery. A pig tail catheter was placed in the right coronary
cusp of aortic root and a decapolar catheter was placed into coronary
sinus. After transseptal puncture an 8F SL1TM (St.Jude
Medical) sheath was inserting into the left atrium from right femoral
vein, suddenly the patient took a deep breath after a short period of
apnea. We heard a vacuum voice. Blood pressure and oxygen saturation
started to drop. We saw a mobile, large air bubble in main pulmonary
artery with total occlusion of all lumen of the vessel on screen(Video 1). Intravenous unfractionated heparin (100 U/kg) and
100 % oxygen was administered immediately. Another pigtail catheter was
taken. The pigtail catheter was inserted into pulmonary artery via 8F
sheath from right femoral vein. Air bubble was dispersed by hitting on
it with the pigtail catheter and pulmonary flow was achieved in a few
seconds. Air bubble was disseappeared (Video 2). Hemodynamic
instability was recovered.The transthoracic echocardiography (ECHO) did
not show any abnormality and procedure was gone. The transseptal sheath
(8F SL1™, St. Jude Medical) was inserted into the left atrium and sheath
was replaced with a FlexCath Advance™ sheath (Medtronic) by controlling
for any air. The isolation of all 4 pulmonary veins with cryoballoon
catheter (Medtronic) was finished without any problem after hemodynamic
stability (Video 3). ECG was taken and transthoracic ECHO was
performed after procedure. Incomplete right bundle branch block (RBBB)
was seen on ECG (Figure 1A-B). But ECHO did not show any
abnormality including tricuspit regurgitation, right ventricular
dysfunction or pericardial effusion. The patient had no any symptoms
including dyspnea, chest pain or palpitation after procedure The
incomplete RBBB was disappeared three hours later after procedure(Figure 1C). The computed tomography of pulmonary angiography
was taken after procedure and it showed no abnormality (Figure
2). Also, pulmonary ventilation-perfusion sintigraphy was taken and
there was no obvious pulmonary embolism findings (Figure 3).The patient was taken lower molecular weight heparin intravenous twice a
day during hospital stay for three days. He was discharged from hospital
treatment with ramipril 5 mg once a day, rivaroxaban 20 mg once a day.