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.