Severe Hemoptysis Caused by Right Inferior Pulmonary Vein Perforation During Circular-Array Pulsed-Field Ablation

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BACKGROUND: Pulsed-field ablation (PFA) has emerged as a novel energy source for pulmonary vein isolation in atrial fibrillation. Although generally safe, rare complications may occur during catheter manipulation in challenging pulmonary veins. CASE SUMMARY: A 71-year-old man underwent PFA with a circular-array catheter for paroxysmal atrial fibrillation. Echocardiography showed preserved left ventricular systolic function and a left atrial diameter of 39 mm. The right inferior pulmonary vein (RIPV) measured 15 mm at the ostium but bifurcated immediately, complicating catheter advancement. During circular-array catheter manipulation in RIPV, oxygen desaturation occurred, requiring endotracheal intubation. Hemoptysis developed, and bronchoscopy revealed bleeding from the right-lower-lobe bronchus, suggesting RIPV perforation. Idarucizumab and protamine were administered, and contrast-enhanced computed tomography confirmed extravasation. Bleeding resolved with supportive care, and the patient was discharged after 13 days. DISCUSSION: This case highlights a rare but serious complication associated with challenging RIPV anatomy during PFA. TAKE-HOME MESSAGE: Careful manipulation of a guidewire and a circular-array catheter is essential in narrow, branching pulmonary vein to prevent vascular injury.

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