Author + information
- Received October 24, 2017
- Revision received December 4, 2017
- Accepted December 7, 2017
- Published online April 16, 2018.
- Tomoaki Nakano, MD,
- Akio Hirata, MD, PhD,
- Yohei Sotomi, MD∗ ( and )
- Yoshiharu Higuchi, MD, PhD
- ↵∗Address for correspondence:
Dr. Yohei Sotomi, Department of Cardiology, Osaka Police Hospital, 10-31, Kitayama, Tennoji, Osaka 543-0035, Japan.
A 69-year-old man with chronic pulmonary emphysema (Figure 1A) underwent radiofrequency catheter ablation for long-standing persistent atrial fibrillation. Pre-procedural transesophageal echocardiography revealed an atrial septal aneurysm. Computed tomography (CT) before ablation (Figure 1B) showed the lung being located posterior to the left atrium (blue arrowhead in Figure 1C). Right atriography clearly demonstrated the septal aneurysm (Figures 1D and 1E, white dotted line indicates septal border line and red shadow indicates atrial septal aneurysm). We had difficulty with the transseptal puncture despite assistance with an radiofrequency needle, intracardiac echocardiography, and fluoroscopy (Figures 1F and 1G). Pulmonary vein isolation was accomplished, albeit unstable hemodynamics during the procedure. Contrast-enhanced CT revealed right hemothorax that might be caused by the septal puncture (Figures 1H and 1I, red circle indicates extravasation). Bleeding (red circle in Figure 1K) from the posterior wall of left atrium into the right thoracic cavity was surgically treated (Figure 1J, thoracoscopic view from the direction of the white arrow in Figure 1H; white arrowheads indicate vertebra; corresponding red, yellow, and blue lines in Figures 1H and 1J) (Online Video 1).
The radiofrequency needle presumably reached to the posterior wall of left atrium due to the septal aneurysm. The incidence of septal aneurysm is reportedly 8.0% (1). Pulmonary emphysema is one of the most frequent incidental findings (15.8%) in CT performed before catheter ablation for atrial fibrillation (2). Coexistence of atrial septal aneurysm and pulmonary emphysema might be a major risk factor of the present rare complication of right hemothorax.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
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- Received October 24, 2017.
- Revision received December 4, 2017.
- Accepted December 7, 2017.
- 2018 American College of Cardiology Foundation