Comprehensive Review of Pulmonary Hemoptysis After Cryoballoon Ablation of Atrial Fibrillation: A Serious Problem Needs Special Care

*Alaa Solaiman Algazzar
Department Of Cardiology, Ahmed Maher Teaching Hospital, Cairo, Egypt

*Corresponding Author:
Alaa Solaiman Algazzar
Department Of Cardiology, Ahmed Maher Teaching Hospital, Cairo, Egypt

Published on: 2020-08-04


To review the literature and published data for pulmonary hemorrhage and hemoptysis after cryo-balloon ablation of atrial fibrillation. PubMed, Embase, Medline, Scopus, Web of Science, and Cochrane Library were searched for published articles and case reports. Our review and search have no restrictions on regions but were limited to human case reports and case series and articles published in English language. We also manually reviewed the publications reference lists to identify other relevant studies. The data was set until first of March 2020 with total of 93 cases out of 2064 with hemoptysis after CBA. From 9 studies a total of 2051 patients with mean age of 57.9±4.3 years had CBA for AF. These studies reported 80 cases with hemoptysis with incidence of 3.9%. The mean follow-up duration ranged from 1 to 12 months. Published cases showed onset of hemoptysis within the first day (47.5%) up to 7 (47.5%) days after CBA. Only 5 cases with massive hemoptysis have been reported during the procedure and 80% of reported cases presented with mild hemoptysis. Mean number of applications for CBA was 2.3±0.9 and mean duration of application was 235.9±57.8 seconds. Recently a concern has been raised about pulmonary complications post CBA. The long-term sequelae of CBA to the lungs are, thus far, unexplored. This review highlights that hemoptysis post CBA is not uncommon and can be avoided by careful selection of patients with careful manipulation during isolation of LSPV and RIPV with optimized freezing temperature will decrease hemoptysis incidence in the near future. The Positive aspect is that most of patients present with mild form of hemoptysis but with the fact that this complication has delayed occurrence.


Pulmonary Hemoptysis; Cryo-balloon; Ablation; Atrial Fibrillation; Lung Injury; Pulmonary Veins Isolation; PVI; Cryo-balloon Complications


Randomized trials showed superiority of AF ablation in comparison to antiarrhythmic drugs (AADs) in terms of improving the quality of life in AF patients. It is recommended that catheter ablation is more effective therapy than AADs for restoring and maintaining sinus rhythm (SR) in patients with symptomatic paroxysmal AF (PAF) and persistent AF (PerAF) [1].
Currently AF ablation is one of the most commonly performed procedures in electrophysiology. The cornerstone of paroxysmal AF ablation is the elimination of triggers by pulmonary vein isolation (PVI). But it is further noted that additional AF substrates modification are needed for ablation of persistent AF on top of PVI. Nowadays, radiofrequency ablation (RFA) navigated by 3D electro-anatomical mapping systems and cryo-balloon innovation are similar in terms of the efficacy and safety of the pulmonary vein isolation (PVI) approach [2]. The FIRE AND ICE trial, a large, randomized, controlled study, showed that CBA is not inferior to RFA with respect to efficacy and overall safety [3]. After the introduction of the second-generation cryo-balloon (CB-2), it has been proved that CBA is a rapid, effective, and safe strategy [4]. However, cryo-balloon ablation still has some week points, including an inability to perform ablation of atrial roof, complex fractionated atrial electrograms (CFAEs) and non-pulmonary veins (PVs) triggers [5]. Although the number of pulmonary veins CBA procedures is increased, there is growing interest in evaluating procedure-related complications described and take steps to minimize their incidence.

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