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.