Management of pulmonary vein rupture after percutaneous intervention: Utility of a hybrid approach

Percutaneous intervention of subtotally occluded pulmonary veins can be difficult owing to the cicatrized nature of the stenotic vein tissue. A 55-year-old man with complete left superior and left inferior pulmonary vein occlusions 4 years after repeated atrial fibrillation radiofrequency ablations for symptomatic paroxysmal atrial fibrillation underwent sequential angioplasty, during which an uncovered stent was placed and expanded 2 mm from the pulmonary vein ostium. Hemodynamics rapidly deteriorated, and intracardiac echocardiogram confirmed pericardial tamponade. Median sternotomy was rapidly performed, and a tear encompassing approximately one-third of the circumference of the fibrotic and scarred left upper pulmonary vein was identified. The patient was supported on cardiopulmonary bypass, the heart was arrested, the left atrium was opened, and a covered 10-mm × 10-cm Viabahn covered stent was inserted. Additional external repair of pulmonary vein/epicardial tissue was performed to completely seal the perforation.