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2025 AF Symposium
Challenging Cases in AF Management: Patient with Bronchial Lesion Leading to Death
Challenging Cases in AF Management: Patient with Bronchial Lesion Leading to DeathOne of the most interesting sessions at the 2025 AF Symposium was the “Challenging Cases in AF Management and Stroke Prevention” on Saturday January 17 at 3:00 pm. (This session was also the least attended, probably because attendees leave early to catch transportation back home.)
This is the first of my reports on these Challenging Cases.
The panelists this year were:
The moderator was Dr. David Keane of St. Vincent’s Hospital, Dublin, Ireland
• Edward Gerstenfeld of the Un. of California (UCSF Health), San Francisco, CA
• Francis Marchlinski of the Un. of Pennsylvania Health System, Philadelphia, PA
• John Day of St. Mark’s Hospital, Salt Lake City, UT
• Isabel Diesenhofer of the German Heart Center Munich, Germany
• Young-Hoon Kim of the Korean University Medical Center, Seoul, Korea
Each doctor made a 7-minute presentation of their case followed by a 5-minute discussion.
Dr. Gerstenfeld found out about this case after the patient was transferred to UCSF Health and underwent surgery.
Case #1: Patient with Bronchial Lesion
Dr. Edward P. Gerstenfeld
Dr. Edward P. Gerstenfeld, chief of the UCSF Cardiac Electrophysiology and Arrhythmia Service, described the tragic case of a man in his 50s who had received a standard Pulmonary Vein Isolation (PVI) procedure.
He had cardiomyopathy [making it harder for the heart to pump blood] and was prescribed the antiarrhythmic drug amiodarone. The ablation appeared to go well without any particular problems. No additional roof or other ablation lines were added to the PVI.
ER Visits for Left Lung Problems
Over the following three weeks the patient had repeated Emergency Room visits, chest pain, cough, shortness of breath, fever, and headache.
Chest X-rays showed multifocal problems particularly in the left lung. He was admitted to the hospital for an IV of antibiotics [to quickly enter his system]. He fainted during bowel movements and had seizure activity.
He was admitted and treated at various hospitals.
A brain CT [computed tomography] was negative. A brain MRI [magnetic resonance imaging] showed a possible left parietal lobe stroke. There was blood with clots in his left main stem bronchus. He was coughing up blood [hemoptysis].
His PVs had a connection to the left bronchus. (The bronchi run just posterior [behind] to the pulmonary vein.)
Posterolateral view of the left bronchial arteries
Transferred to UCSF Health Pulmonary Service
He was eventually transferred to the UCSF Health Pulmonary Service. He had more coughing up of blood and had to be paralyzed.
A lesion [area of damaged or abnormal tissue] was found in his distal left main stem bronchus. Using Ultrasound and a new CT found a PV vessel was underneath his left bronchus. There was no esophageal damage.
Anatomy of the pulmonary and bronchial circulation
A Stent Didn’t Work, the Patient Died
Surgeons were unclear about bypass because of his left parietal stroke. A covered stent was placed in his left pulmonary vein.
Despite the stent, the patient developed more hemoptysis [coughing up blood] and his heart arrested [stopped]. Tragically the patient passed away.
Research and Anatomy of Bronchi Contact with Pulmonary Veins
Dr. Gerstenfeld talked about research articles describing the relationship between the bronchi and pulmonary veins which run closely together within the lungs. The bronchi can sometimes connect to the pulmonary veins.
In one study 70 patients’ bronchi were in direct contact with the PVs, usually the superior ones, and were at risk of bronchial injury.
Dr. Gerstenfeld described this patient’s death as a very unusual complication. He added that this type of bronchial injury is unlikely with the newer ablation technique of Pulsed Field Ablation (PFA).
Editor’s Comments:
Editor’s Comments:I had never heard of a PVI affecting the bronchi and lungs.
In some people the upper pulmonary veins are close to and overlap the lung bronchi. When doing a PVI, it’s possible, though very rare, that the RF catheter may make a lesion in a lung bronchus. This can lead to a dangerous complication that resembles an Atrial Esophageal Fistula (an unintended hole formed between the atrium and the esophagus).
This is what happened to this patient, only the hole was between the atrium and the left bronchus.
What PVI Patients Need to Know: After a catheter ablation, if you start feeling poorly let your doctor know immediately. A complication like a lesion in a lung bronchus (an atrial esophageal fistula) can be fixed if caught in time.
