Wire perforation causing cardiopulmonary arrest during radiofrequency hot balloon ablation for pulmonary vein isolation.

A 73-year-old woman underwent radiofrequency hot balloon ablation (RHBA) for paroxysmal atrial fibrillation. After delivery into the left inferior pulmonary vein (LIPV), the guidewire perforated the venous wall. We injected contrast medium while the inflated balloon occluded the PV. Subsequently, bronchial-pulmonary venous fistula (BPVF) occurred and the severe hypoxia caused pulseless electrical activity (PEA). Cardiopulmonary resuscitation and intubation quickly recovered spontaneous circulation. She was initially treated by a multidisciplinary team in the intensive care unit and subsequently discharged without sequelae. Although relatively rare, there are some reports of wire perforation during RHBA and cryoballoon ablation. Some cases resolved after discontinuing anticoagulant therapy, while others required invasive procedures. This is the first case in which hypoxia, shock, and PEA were caused by wire perforation. As such complications can occur in all balloon ablation procedures, operators need to take care when using the guidewire and guide catheter. Anticoagulant therapy should be discontinued following PV perforation, if possible. Hemostasis with ventilator management is desirable. If hemostasis cannot be achieved, lung resection must be considered. Although wire perforation causing BPVF is rare, establishment of preventive measures and treatment protocols is needed. <Learning objective: The safety of radiofrequency hot balloon (RHB) ablation for paroxysmal atrial fibrillation has been established. This case report presents the rare complication of a soft J-tipped guidewire perforating the pulmonary vein (PV) without any resistance. Pulmonary venography was performed with the RHB blocking the PV, eventually causing pulseless electrical activity from hypoxia due to a bronchial-pulmonary venous fistula. Artificial ventilation management by positive end expiratory pressure after discontinuing anticoagulant therapy was effective for hemostasis and improvement of respiratory condition.>.