A 35-year-old male patient, with persistent AF refractory to the pharmacologic treatment underwent RFA in our hospital. As a routine practice in our centre, the patient was assessed pre-procedurally by transesophageal echocardiography (TEE) on the day of procedure to delineate anatomy of pulmonary veins and left atrium (LA) and to exclude LA appendage thrombus. During RFA procedure all four PV were individually isolated under guidance of intracardiac echocardiography. RF energy was delivered using a conventional 4 mm and 8 mm tip ablation catheters and a power setting of 30 W, 50  C around a circular decapolar catheter located at the pulmonary veins ostia. Application of the RF was immediately interrupted when microbubbles were detected by the intracardiac echocardiography (ICE). After a curative ablation therapy patient was kept on aspirin to prevent pulmonary venous or arterial thrombosis and recurrence of AF. Ambulatory follow-up cardiac computed tomography (CT) angiogram was done 3 months following RFA and showed approximately 60% left superior PVS but no intervention was performed because the patient was asymptomatic and he was kept on oral anticoagulation (Figure 1).
Two months later, the patient developed cough associated with hemoptysis, mild intermittent fever, mild left-sided pleuritic chest pain and shortness of breath on exertion. He visited the primary health centre close to his residency where chest radiography was done and showed left upper lobe poorly marginated opacities and minimal left pleural effusion. Further laboratory studies were done to rule out pulmonary tuberculosis (TB) which were within normal limits. A definitive diagnosis was not made and the patient was given broad spectrum antibiotics and referred to pulmonology clinic in our hospital for further investigation.
Patient presented to our hospital 6 months after ablation without improvement in the symptoms. Non-enhanced CT was done and showed increased parenchymal attenuation and multiple peripheral patchy consolidations in the apico-posterior and anterior segments of left upper lobe associated with minimal left pleural effusion (Figure 2a and b). Cryptogenic organizing pneumonia (COP), chronic eosinophilic pneumonia (CEP), fungal infection (pulmonary aspergillosis), lung cancer and primary pulmonary lymphoma were suggested as differential diagnosis and ultrasound-guided aspiration of the left-sided pleural effusion was carried out and the obtained specimen was fluid of serous nature. Besides that, lung biopsy was also performed and the histopathologic examination revealed surprisingly intimal hyperplasia associated with multifocal haemorrhagic infarction due to PVO and hypertensive pulmonary arteriopathy. After that contrast-enhanced CT scan was performed with 3D reconstruction and manifested clearly an occluded left superior pulmonary vein (LSPV) (Figure 2c and d). Occlusion was confirmed by conventional angiography. Ventilation/perfusion scan demonstrated absent perfusion of the involved lung parenchyma and left upper lobectomy was warranted.