Darcy D. Marciniuk, MD, FCCP Saskatoon, SK, Canada Chen Wang, MD, PhD, FCCP Beijing, China Affiliations: From the Department of Pulmonary and Critical Care Medicine (Dr Qiao), Keck School of Medicine, University of Southern California; the American College of Chest Physicians (Dr Rosen); First Affiliated Hospital of Guangzhou Medical College (Dr Chen), Guangzhou Institute of Respiratory Diseases; Beijing Hospital (Dr Wu), Ministry of Health; the Division of Respirology, Critical Care and Sleep Medicine (Dr Marciniuk), University of Saskatchewan, Royal University Hospital; and the Chinese Thoracic Society (Dr Wang), Beijing Hospital, Ministry of Health, Beijing Institute of Respiratory Medicine, National Clinical Research Centre for Respiratory Medicine. Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article. Correspondence to: Mark J. Rosen, MD, Master FCCP, 2595 Patriot Blvd, Glenview, IL 60026; e-mail: [email protected] © 2014 American College of Chest Physicians. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details. DOI: 10.1378/chest.14-0593
reports other than the references provided by Martí-Almor et al.2,3 Weig et al4 observed coughing and hemoptysis for three of 83 patients for up to 1 week secondary to a CT scan-documented frozen lung complication. They also observed that hemoptysis was seen only among the patients whose minimum freezing temperature of cryoballoon was , 255°C. Vogt et al5 observed development of cough with reversible hemoptysis in five of 293 patients. In their study, CT scan of the lungs revealed hematomas and edema around a pulmonary vein due to freezing of lung tissue. Notably, the cryoballoons were used for two applications of 6 min per vein. Avitall et al6 electrically isolated pulmonary veins using cryoballoon ablation in dogs. However, within 24 to 48 h, hemoptysis developed in most of the animals due to freezing extension from the left atrium to the lungs. In an earlier animal study, after thoracotomy, Neel et al7 froze lung tissue with a freezing probe without penetrating the lung. After thawing, hemorrhagic infarctions were observed. The treating physicians need to be cautious about hemoptysis not only during cryoballoon ablation but also during patient follow-up. Narendra Kumar, MD Carl Timmermans, MD, PhD Laurent Pison, MD, PhD Harry Crijns, MD, PhD Maastricht, The Netherlands
References 1. Qiao R, Rosen MJ, Chen R, Wu S, Marciniuk D, Wang C; on behalf of the CTS-ACCP Pulmonary and Critical Care Medicine Workgroup. Establishing pulmonary and critical care medicine as a subspecialty in China: joint statement of the Chinese Thoracic Society and the American College of Chest Physicians. Chest. 2014;145(1):27-29. 2. ACGME program requirements for graduate medical education in pulmonary disease and critical care medicine (internal medicine). Accreditation Council for Graduate Medical Education website. http://www.acgme.org/acgmeweb/Portals/0/ PFAssets/2013-PR-FAQ-PIF/156_pulmonary_critical_care_ int_med_07132013.pdf. Accessed February 17, 2014. 3. Du B, Xi X, Chen D, Peng J; China Critical Care Clinical Trial Group (CCCCTG). Clinical review: critical care medicine in mainland China. Crit Care. 2010;14(1):206. 4. Wang C, Xiao F, Qiao R, Shen YH. Respiratory medicine in China: progress, challenges, and opportunities. Chest. 2013; 143(6):1766-1773. 5. Duke EM. Health Resources & Services Administration, US Department of Health & Human Services. Report to Congress: the critical care workforce: a study of the supply and demand for critical care physicians. Requested by Senate report 108-81, Senate report 109-103, and House Report 109-143. Health Resources & Services Administration website. http://bhpr. hrsa.gov/healthworkforce/reports/studycriticalcarephys.pdf. Accessed June 23, 2013.
Hemoptysis Déjà Vu for Cryoballoon Use for Pulmonary Vein Isolation for Atrial Fibrillation Ablation To the Editor: In a recent issue of CHEST (January 2014), Martí-Almor et al1 elegantly described a case report of pulmonary hemorrhage after cryoballoon ablation for atrial fibrillation. At Maastricht University Medical Centre, we also came across patients with similar presentations. There has been an upsurge in similar, but sporadic case journal.publications.chestnet.org
Affiliations: From the Department of Cardiology, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht. Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article. Correspondence to: Narendra Kumar, MD, Department of Cardiology, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht, PO Box 5800, 6202 AZ, Maastricht, The Netherlands; e-mail: [email protected] © 2014 American College of Chest Physicians. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details. DOI: 10.1378/chest.14-0236
References 1. Martí-Almor J, Jauregui-Abularach ME, Benito B, et al. Pulmonary hemorrhage after cryoballoon ablation for pulmonary vein isolation in the treatment of atrial fibrillation. Chest. 2014;145(1):156-157. 2. van Opstal JM, Timmermans C, Blaauw Y, Pison L. Bronchial erosion and hemoptysis after pulmonary vein isolation by cryoballoon ablation. Heart Rhythm. 2011;8(9):1459. 3. Conte G, Chierchia GB, Casado-Arroyo R, Ilsen B, Brugada P. Pulmonary vein intramural hematoma as a complication of cryoballoon ablation of paroxysmal atrial fibrillation. J Cardiovasc Electrophysiol. 2013;24(7):830-831. 4. Weig HJ, Weretka S, Parade U, et al. Cryo-specific complications using the single big cryoballoon technique for pulmonary vein isolation in patients with paroxysmal atrial fibrillation [abstract]. Eur Heart J. 2010;31(suppl 1):556. 5. Vogt J, Heintze J, Noelker BG, et al. Side effects and success of antral isolation of pulmonary veins with cryoballoon technique in a large patient cohort with atrial fibrillation [abstract]. Eur Heart J. 2009;30(suppl 1):813. 6. Avitall B, Lafontaine D, Rozmus G, et al. The safety and efficacy of multiple consecutive cryo lesions in canine pulmonary veins-left atrial junction. Heart Rhythm. 2004;1(2):203-209. 7. Neel HB III, Farrell KH, Payne WS, DeSanto LW. Cryosurgery of respiratory structures. II. Cryonecrosis of the lung. Laryngoscope. 1974;84(3):417-426. CHEST / 145 / 6 / JUNE 2014
1435
reports other than the references provided by Martí-Almor et al.2,3 Weig et al4 observed coughing and hemoptysis for three of 83 patients for up to 1 week secondary to a CT scan-documented frozen lung complication. They also observed that hemoptysis was seen only among the patients whose minimum freezing temperature of cryoballoon was , 255°C. Vogt et al5 observed development of cough with reversible hemoptysis in five of 293 patients. In their study, CT scan of the lungs revealed hematomas and edema around a pulmonary vein due to freezing of lung tissue. Notably, the cryoballoons were used for two applications of 6 min per vein. Avitall et al6 electrically isolated pulmonary veins using cryoballoon ablation in dogs. However, within 24 to 48 h, hemoptysis developed in most of the animals due to freezing extension from the left atrium to the lungs. In an earlier animal study, after thoracotomy, Neel et al7 froze lung tissue with a freezing probe without penetrating the lung. After thawing, hemorrhagic infarctions were observed. The treating physicians need to be cautious about hemoptysis not only during cryoballoon ablation but also during patient follow-up. Narendra Kumar, MD Carl Timmermans, MD, PhD Laurent Pison, MD, PhD Harry Crijns, MD, PhD Maastricht, The Netherlands
References 1. Qiao R, Rosen MJ, Chen R, Wu S, Marciniuk D, Wang C; on behalf of the CTS-ACCP Pulmonary and Critical Care Medicine Workgroup. Establishing pulmonary and critical care medicine as a subspecialty in China: joint statement of the Chinese Thoracic Society and the American College of Chest Physicians. Chest. 2014;145(1):27-29. 2. ACGME program requirements for graduate medical education in pulmonary disease and critical care medicine (internal medicine). Accreditation Council for Graduate Medical Education website. http://www.acgme.org/acgmeweb/Portals/0/ PFAssets/2013-PR-FAQ-PIF/156_pulmonary_critical_care_ int_med_07132013.pdf. Accessed February 17, 2014. 3. Du B, Xi X, Chen D, Peng J; China Critical Care Clinical Trial Group (CCCCTG). Clinical review: critical care medicine in mainland China. Crit Care. 2010;14(1):206. 4. Wang C, Xiao F, Qiao R, Shen YH. Respiratory medicine in China: progress, challenges, and opportunities. Chest. 2013; 143(6):1766-1773. 5. Duke EM. Health Resources & Services Administration, US Department of Health & Human Services. Report to Congress: the critical care workforce: a study of the supply and demand for critical care physicians. Requested by Senate report 108-81, Senate report 109-103, and House Report 109-143. Health Resources & Services Administration website. http://bhpr. hrsa.gov/healthworkforce/reports/studycriticalcarephys.pdf. Accessed June 23, 2013.
Hemoptysis Déjà Vu for Cryoballoon Use for Pulmonary Vein Isolation for Atrial Fibrillation Ablation To the Editor: In a recent issue of CHEST (January 2014), Martí-Almor et al1 elegantly described a case report of pulmonary hemorrhage after cryoballoon ablation for atrial fibrillation. At Maastricht University Medical Centre, we also came across patients with similar presentations. There has been an upsurge in similar, but sporadic case journal.publications.chestnet.org
Affiliations: From the Department of Cardiology, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht. Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article. Correspondence to: Narendra Kumar, MD, Department of Cardiology, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht, PO Box 5800, 6202 AZ, Maastricht, The Netherlands; e-mail: [email protected] © 2014 American College of Chest Physicians. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details. DOI: 10.1378/chest.14-0236
References 1. Martí-Almor J, Jauregui-Abularach ME, Benito B, et al. Pulmonary hemorrhage after cryoballoon ablation for pulmonary vein isolation in the treatment of atrial fibrillation. Chest. 2014;145(1):156-157. 2. van Opstal JM, Timmermans C, Blaauw Y, Pison L. Bronchial erosion and hemoptysis after pulmonary vein isolation by cryoballoon ablation. Heart Rhythm. 2011;8(9):1459. 3. Conte G, Chierchia GB, Casado-Arroyo R, Ilsen B, Brugada P. Pulmonary vein intramural hematoma as a complication of cryoballoon ablation of paroxysmal atrial fibrillation. J Cardiovasc Electrophysiol. 2013;24(7):830-831. 4. Weig HJ, Weretka S, Parade U, et al. Cryo-specific complications using the single big cryoballoon technique for pulmonary vein isolation in patients with paroxysmal atrial fibrillation [abstract]. Eur Heart J. 2010;31(suppl 1):556. 5. Vogt J, Heintze J, Noelker BG, et al. Side effects and success of antral isolation of pulmonary veins with cryoballoon technique in a large patient cohort with atrial fibrillation [abstract]. Eur Heart J. 2009;30(suppl 1):813. 6. Avitall B, Lafontaine D, Rozmus G, et al. The safety and efficacy of multiple consecutive cryo lesions in canine pulmonary veins-left atrial junction. Heart Rhythm. 2004;1(2):203-209. 7. Neel HB III, Farrell KH, Payne WS, DeSanto LW. Cryosurgery of respiratory structures. II. Cryonecrosis of the lung. Laryngoscope. 1974;84(3):417-426. CHEST / 145 / 6 / JUNE 2014
1435
