Hemoptysis and Bloody Pleural Effusion in Atrial Fibrillation Patients Post-Radiofrequency Ablation: two Case Report and Mechanistic Discussion

Hemoptysis and Bloody Pleural Effusion in Atrial Fibrillation Patients Post-Radiofrequency Ablation: two Case Report and Mechanistic Discussion | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Hemoptysis and Bloody Pleural Effusion in Atrial Fibrillation Patients Post-Radiofrequency Ablation: two Case Report and Mechanistic Discussion HongJun Zhang, TianTian Ma, Xing Gu, Jian LI, Xiaoyan Zhang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6433927/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 14 You are reading this latest preprint version Abstract Atrial fibrillation (AF) is the most common arrhythmia in clinical practice. Developing pulmonary vein stenosis (PVS) after surgery can lead to serious symptoms, including chest pain, coughing up blood, and bloody pleural effusion. This study reviews two patients who developed PVS after AF radiofrequency ablation. It examines their clinical manifestations and the effectiveness of percutaneous pulmonary vein stenting. Through case analysis and literature review, we describe the clinical courses of two patients. Case 1, a 66-year-old male, presented with chest pain and bloody pleural effusion and showed significant improvement after pulmonary vein stenting. Case 2, a 52-year-old male, experienced recurrent coughing up blood, with symptoms that completely resolved after stenting. The findings suggest that percutaneous pulmonary vein stenting is very effective in alleviating symptoms associated with pulmonary vein stenosis. Despite the limited sample size, the results indicate that this treatment method offers an effective management option for AF patients. It highlights the need for individualized treatment and further exploration of the pathological mechanisms linking AF and PVS. Future larger-scale prospective studies are needed to verify the long-term safety and efficacy of this method to optimize clinical management strategies. Atrial fibrillation Radiofrequency Ablation Pulmonary venous occlusion Figures Figure 1 Figure 2 Introduction Current medical research focuses on the electrophysiological mechanisms of atrial fibrillation (AF). AF is the most common clinical arrhythmia, marked by chaotic and disorganized atrial electrical activity, resulting in irregular atrial contractions 1 . Recently, the widespread use of radiofrequency ablation has complicated AF management, especially with the emergence of pulmonary vein stenosis (PVS) and postoperative pulmonary vein occlusion, both of which have drawn significant attention. PVS is regarded as one of the most serious complications after AF radiofrequency ablation, significantly affecting patients' quality of life 2 . Despite numerous studies on the electrophysiological mechanisms of AF, significant gaps remain in understanding how PVS occurs. Research shows that AF onset is linked to several electrophysiological factors. These include increased atrial automaticity, reentrant excitation, and abnormal electrical conduction 3 . Furthermore, the persistent presence of AF may lead to atrial tissue remodeling, exacerbating the occurrence of electrophysiological abnormalities 4 . Therefore, a thorough investigation of the relationship between the electrophysiological mechanisms of AF and PVS occurrence will provide a vital theoretical basis for clinical research. Currently, treatment methods for PVS mainly include interventional therapy and surgical procedures. However, most existing studies are small-scale and retrospective, lacking systematic large-scale prospective research to assess the efficacy and safety of various treatment options 5 . Thus, further research into the pathophysiological mechanisms of PVS and its treatment methods is still needed. This study reviews two patients who developed post-ventricular tachycardia syndrome (PVS) after undergoing radiofrequency ablation for atrial fibrillation (AF). It analyzes their clinical manifestations and treatment outcomes. We will examine how effective percutaneous pulmonary vein stenting is in alleviating patient symptoms, using detailed case descriptions.The research methods involve case analysis and a literature review, aiming to provide new insights for the clinical management of atrial fibrillation patients and establish a theoretical foundation for future research. Case Presentation 1. Case 1 1.1 Demographics: 66-year-old male, teacher. 1.2 Chief complaint: Left-sided chest pain for over 2 months. 1.3 Medical history: Sudden onset of left chest pain without obvious triggers over 2 months ago, no radiation of pain, symptoms alleviated with rest. Presented at a local hospital, a chest CT showed some patchy areas of increased density in the left upper lobe and a small amount of left pleural effusion. T-SPOT: positive. The cause was unclear after examination, and the patient was treated for tuberculosis for a month, with no significant relief of chest pain. Pulmonary vein CTA showed reduced blood flow perfusion in the left pulmonary vein. 1.4 Treatment history (Figure 1 A): 40 years ago underwent surgical repair for atrial septal defect; persistent AF developed in July 2022, underwent AF radiofrequency ablation + left atrial appendage occlusion; in April 2023, unexplained hemorrhagic pleural effusion occurred, underwent diagnostic anti-tuberculosis treatment; on May 9, 2023, pulmonary vein CTA showed reduced blood flow perfusion in the left pulmonary vein (Figure 2A), left atrial appendage occluder (Figure 2B), and a small amount of left pleural effusion (Figure 2C); on May 27, 2023, underwent percutaneous pulmonary vein stenting, postoperative angiography showed unobstructed flow in the left upper and lower pulmonary veins; on August 25, 2023, follow-up pulmonary vein CTA showed good positioning of the left upper and lower pulmonary vein stents, with unobstructed blood flow (Figure 2D). 1.5 Diagnostic challenges: Chest CT and pleural ultrasound were performed due to left-sided chest pain, revealing a small amount of left pleural effusion. Closed drainage of the pleural cavity yielded red, turbid effusion, specific gravity 1.018, Lieberman test positive, white blood cell count 2128×10^6/L, with lymphocytes accounting for 85% and neutrophils for 15%. T-SPOT: positive. The pleural effusion was likely exudative. Among the most common exudative pleural effusions clinically, malignant pleural effusion was excluded, and diagnostic anti-tuberculosis treatment was given for over a month, with no significant relief of chest pain and no disappearance of pleural effusion. Only after performing pulmonary vein CTA was reduced blood flow perfusion in the left pulmonary vein discovered. 1.6 Treatment plan: On May 27, 2023, underwent percutaneous pulmonary vein stenting. Routine disinfection and draping were performed, and after local anesthesia, successful puncture of the left and right femoral veins was achieved, followed by the placement of a vascular sheath. Pulmonary vein angiography indicated severe stenosis (98%) of the left upper pulmonary vein, with occlusion of the left lower pulmonary vein. A catheter was advanced from the inferior vena cava to the right atrium, puncturing the interatrial septum to the left atrium, and a guidewire was sent into the left upper pulmonary vein. A 4mm balloon was used to dilate the left upper pulmonary vein, followed by the implantation of a 10*19mm stent, with angiography showing unobstructed flow in the left upper pulmonary vein. Attempts were made to open the left lower pulmonary vein; after the guidewire passed through the left lower pulmonary vein, a 3.4mm balloon was used for dilation, and a 10*19mm stent was implanted after the catheter passed through the stenosis, with angiography showing unobstructed flow in the left lower pulmonary vein. 1.7 Outcome: Postoperatively, the patient's chest pain and pleural effusion disappeared. Three months later, follow-up showed stable condition, and pulmonary vein CTA indicated good positioning of the left upper and lower pulmonary vein stents, with unobstructed blood flow (Figure 2D). 2. Case 2 2.1 Demographics: 52-year-old male, employee. 2.2 Chief complaint: Recurrent coughing up blood for over 1 year. 2.3 Medical history: Coughing up blood occurred over 1 year ago, with two previous bronchial artery embolization procedures for hemostatic treatment. On October 8, 2024, after a cold, coughing up blood recurred, initially with blood-streaked sputum, accompanied by chest tightness and shortness of breath, occasional cough and sputum production, with poor response to hemostatic medication. On October 15, 2024, massive coughing up blood occurred, approximately 200ml, bright red. Emergency hospitalization followed. 2.4 Treatment history (Figure 1B): History of AF for over 2 years, previously underwent radiofrequency ablation treatment three times; history of bronchiectasis for over 1 year, with two previous bronchial artery embolization procedures for coughing up blood; on October 8, 2024, blood-streaked sputum occurred; on October 15, 2024, massive coughing up blood occurred, approximately 200ml; chest CTA examination: left upper pulmonary vein occlusion (Figure 2 E, G). On October 24, 2024, DSA showed occlusion of the left upper pulmonary vein with significant collateral vessel proliferation and tortuosity; attempts to open the left upper pulmonary vein were unsuccessful; considering coughing up blood originated from the left upper pulmonary artery, a spring coil embolization was performed; on November 9, 2024, underwent percutaneous left upper pulmonary vein stenting, with postoperative angiography showing unobstructed flow in the left upper pulmonary vein; on December 13, 2024, follow-up chest CTA showed tubular dense shadow in the left pulmonary vein trunk (Figure 2 F, H). 2.5 Diagnostic challenges: The patient experienced recurrent coughing up blood, stopping after multiple bronchial artery and left upper pulmonary artery embolization procedures, but then recurring. Ultimately, percutaneous left upper pulmonary vein stenting was performed, resulting in complete resolution of coughing up blood symptoms. 2.6 Treatment plan: On November 9, 2024, underwent percutaneous pulmonary vein stenting. The patient was placed in a supine position, with routine disinfection and draping of the surgical area, and local anesthesia with 2% lidocaine was administered. A percutaneous puncture of the left and right femoral veins was successfully performed using an 18G puncture needle, followed by the placement of a 5F vascular sheath. Using a super slippery guidewire, left upper pulmonary artery angiography was performed, and DSA showed occlusion of the left upper pulmonary vein. Significant collateral vessels were noted, with proliferation and tortuosity. After exchanging the guidewire, a sheath for interatrial septum puncture (minimally invasive TNM7118) was placed, and an interatrial septum puncture needle was sent in to perform the puncture. After successfully entering the left atrium, a guidewire (Abbott) was used to guide the catheter through the interatrial septum, successfully opening the left upper pulmonary vein. A PTA balloon dilation catheter was sent in for dilation, and follow-up angiography showed blood flow through, though still narrowed. A peripheral stent (19*130) was sent in via the guidewire, and follow-up angiography showed the stent was well placed, with unobstructed blood flow and no stenosis. 2.7 Outcome: Postoperatively, the patient's coughing up blood symptoms disappeared. One month later, follow-up showed stable condition, and pulmonary vein CTA indicated good positioning of the left upper pulmonary vein stent, with unobstructed blood flow. 3. Comparative analysis (see Table 1): 3.1 Similarities: Both cases developed pulmonary vein stenosis or occlusion after AF radiofrequency ablation. 3.3 Differences: Case 1 presented with chest pain and bloody pleural effusion, while Case 2 presented with recurrent coughing up blood. 3.4 Treatment effect: Pulmonary vein stenting relieved pulmonary vein stenosis and occlusion, leading to rapid symptom resolution and good treatment outcomes. Discussion In contemporary medical research, atrial fibrillation (AF) is the most common arrhythmia, and its pathological mechanisms are a key focus of academic interest. Several factors contribute to the occurrence of AF. These include the electrophysiological characteristics of the atrium, structural abnormalities, and the influence of the autonomic nervous system 1 . The complexity of these mechanisms indicates that the development of AF is not yet fully understood, particularly in relation to pulmonary vein stenosis (PVS). Pulmonary vein stenosis (PVS) is a common complication that can occur after radiofrequency ablation for AF, and it may lead to severe clinical symptoms, including chest pain, hemoptysis, and dyspnea 2 . Therefore, gaining a deeper understanding of the electrophysiological mechanisms of AF and their relationship with pulmonary vein stenosis is essential for enhancing the clinical management of affected patients. This study reviews two cases to analyze the clinical manifestations and treatment outcomes of pulmonary vein stenosis following AF radiofrequency ablation. Case 1 presents with chest pain, while Case 2 exhibits bloody pleural effusion and recurrent hemoptysis, both occurring after AF ablation. Percutaneous pulmonary vein stenting significantly improved the patients' symptoms and restored blood flow. This finding offers new insights into treating pulmonary vein stenosis and highlights the need for individualized treatment plans 6 . The development of pulmonary vein stenosis (PVS) after AF ablation is linked to various pathophysiological mechanisms, which contribute to the complexity of associated symptoms. The pathophysiological mechanisms of pulmonary vein stenosis and their clinical manifestations include RF energy injury, local inflammatory responses, and hemodynamic changes. This study explores the mechanisms underlying symptoms like chest pain, bloody pleural effusion, and hemoptysis. Additionally, this paper will examine changes in clinical manifestations during various postoperative time intervals, offering a theoretical basis for clinical monitoring and early intervention 7 . The occurrence of chest pain is mainly related to hemodynamic changes and local ischemia caused by pulmonary vein stenosis. Existing research shows that pulmonary vein stenosis can lead to insufficient microcirculation perfusion 8 . This insufficiency results in local hypoxia, which stimulates pain receptors and causes ischemic pain. Furthermore, pulmonary congestion and interstitial edema can also affect the pleural space, elevating pleural pressure and worsening chest pain. In severe cases of pulmonary vein stenosis, the opening of pulmonary vein-bronchial artery collaterals may occur, causing turbulent blood flow and further aggravating pain 9 . Bloody pleural effusion is strongly associated with pulmonary venous hypertension and vascular injury. Pulmonary venous hypertension increases the filtration pressure of capillaries. This pressure can exceed the lymphatic system's ability to return fluid, causing protein-rich fluid and red blood cells to leak into the pleural cavity and form effusions 10 . During the ablation procedure, thermal injury from RF energy may directly damage the subpleural vessels, making the vessel walls more fragile and promoting the formation of bloody effusions. Additionally, local inflammatory responses can increase the permeability of pleural vessels by releasing pro-inflammatory factors, which worsens the leakage of bloody fluid 11 . Coughing up blood is mainly linked to pulmonary venous hypertension and the rupture of new blood vessels. Pulmonary venous hypertension can cause blood to flow backward through the bronchial veins. This leads to swelling and rupture of these veins, which results in coughing up blood 12 . Additionally, the formation of new blood vessels in areas with chronic blood supply issues can occur. These new vessels are often imperfect and may rupture when a person coughs or experiences pressure changes, worsening the bleeding 7 . In severe cases of stenosis, a complete blockage of the pulmonary vein can cause lung tissue death, which may lead to the release of dead tissue and result in bleeding 11 . These symptoms are closely linked to the progression of the disease. During the acute phase, patients often experience more severe chest pain and bloody pleural effusion, mainly due to vascular injury and inflammation 10 . In the chronic phase, as pulmonary veins develop fibrosis and experience hemodynamic changes, hemoptysis and worsening dyspnea become more noticeable, suggesting that patient monitoring and management should be adjusted based on the disease progression 12 . Thus, the various pathophysiological mechanisms that cause pulmonary vein stenosis after atrial fibrillation (AF) ablation lead to a range of clinical symptoms. This variability necessitates a thorough assessment of symptoms to enable early intervention and improve patient outcomes. Additionally, our detailed analysis of the two cases shows that percutaneous pulmonary vein stenting effectively improves patient symptoms. In Case 1, the patient had severe chest pain and bloody pleural effusion, both of which improved after the stenting procedure. In Case 2, the patient experienced recurrent hemoptysis, which completely resolved following stenting. These results align with previous studies, demonstrating that pulmonary vein stenting can effectively alleviate symptoms caused by pulmonary vein stenosis. This finding also offers new insights for clinical treatment strategies 2 . This new finding highlights the importance of considering pathophysiological mechanisms in managing patients with atrial fibrillation (AF) to create personalized treatment plans. While the results of this study are clinically significant, there are still limitations. First, the sample size is small, analyzing only two cases, which may limit how broadly the results can be applied. Additionally, because this study is a retrospective analysis, potential biases cannot be fully controlled. Future research should use larger-scale prospective designs. This will help comprehensively evaluate the long-term effects and safety of percutaneous pulmonary vein stenting. Furthermore, exploring early identification and intervention strategies for pathophysiological mechanisms is a crucial direction for future research 13 . In summary, this study shows that percutaneous pulmonary vein stenting works well through case analysis of two patients with pulmonary vein stenosis or occlusion after AF radiofrequency ablation. Although the study has limitations, such as a small sample size and short follow-up time, the results indicate that this treatment can effectively alleviate symptoms and improve pulmonary vein blood flow. This finding provides insights into clinical treatment strategies, emphasizing the importance of individualized approaches. Future research should prioritize assessing long-term effects to enhance the clinical value of this treatment. Abbreviations RRAST - Right-sided Pulmonary Arterial Stenosis PV - Pulmonary Vein PV Stenting - Pulmonary Vein Stenting Pulmonary Artery - Pulmonary Artery AF - Atrial Fibrillation RTV - Right ventricular volume LVEF - Left ventricular ejection fraction ECMO - Extracorporeal Membrane Oxygenation RRAST - Right-sided Pulmonary Arterial Stenosis RV - Right ventricle LA - Left anterior descending coronary artery LAD - Left anterior descending coronary artery SST - Segmental Sumission Therapy PV - Pulmonary Vein Declarations Ethics approval and consent to participate Due to the retrospective nature of this study, we determined that seeking approval from the ethics committee (EC) was not necessary. We have implemented strict measures to protect patient confidentiality by omitting all identifiable information in the manuscript. we believe that anonymizing the patient's data adequately addresses potential privacy concerns. ● Consent for publication The patient's written informed consent has been obtained for publication. ● Availability of data and materials The data presented in this study are available on reasonable request from the first author. ● Competing Interests The authors declare no competing interests. ● Funding This work was supported by grants from Xi'an Science and Technology Plan Project (2022JH-YBYJ-0157). ● Authors' contributions HongJun Zhang: Contributed to data acquisition, clinical analysis, manuscript drafting, and critical revision. TianTian Ma: Participated in case analysis, literature review, and manuscript preparation. Xing Gu: Assisted in clinical data interpretation and manuscript editing. JiAn LI: Performed interventional procedures (pulmonary vein stenting) and contributed to technical analysis. XiaoYan Zhang: Supervised the study, conceptualized the research, critically revised the manuscript, and approved the final version as the corresponding author. All authors reviewed and approved the final manuscript. ● Acknowledgements We extend our sincere gratitude to the patients involved in this study for their consent to share clinical data and for their trust in our medical team. We acknowledge the collaborative efforts of the interventional radiology department at Xi'an Chest Hospital for their expertise in performing pulmonary vein stenting procedures. Special thanks to our nursing staff and clinical colleagues for their diligent patient care and data collection support. We also appreciate the constructive feedback from peer reviewers, which significantly strengthened the manuscript. This work was facilitated by the clinical research infrastructure of Xi'an Chest Hospital, and we remain indebted to our institution for fostering an environment conducive to interdisciplinary collaboration. References Aslan O, Guneri S. [Electrophysiological mechanisms of atrial fibrillation]. Anadolu Kardiyol Derg 2002; 2 (3): 244-52. Pan X, Wang C, Zhang Y, Wu W, Fang W. [Pulmonary vein stenting for the treatment of severe pulmonary vein stenosis after catheter ablation of atrial fibrillation]. Zhonghua Xin Xue Guan Bing Za Zhi 2014; 42 (10): 827-30. Brugada J. [Electrophysiologic mechanisms of atrial fibrillation]. Rev Esp Cardiol 1996; 49 Suppl 2 : 8-12. Delise P. [Electrophysiological mechanisms of atrial tachyarrhythmia]. Cardiologia 1991; 36 (8 Suppl): 11-5. Wong PC, Wang MA, Ng TJ, Akbarialiabad H, Murrell DF. Keratosis pilaris treatment paradigms: assessing effectiveness across modalities. Clin Exp Dermatol 2024; 49 (10): 1105-17. Xu L, Cui L, Hou J, et al. Clinical characteristics of patients with atrial fibrillation suffering from pulmonary vein stenosis after radiofrequency ablation. J Int Med Res 2020; 48 (3): 300060519881555. Chakraborty A, Paudel KR, Wang C, et al. Anti-inflammatory and anti-fibrotic effects of berberine-loaded liquid crystalline nanoparticles. EXCLI J 2023; 22 : 1104-8. Tscheikuna J, Chvaychoo B, Naruman C, Maranetra N. Tranexamic acid in patients with hemoptysis. J Med Assoc Thai 2002; 85 (4): 399-404. Yin BY. [Bronchoscopic evaluation of 390 cases of hemoptysis without definite abnormality on the chest roentgenogram]. Zhonghua Jie He He Hu Xi Za Zhi 1990; 13 (1): 44-6, 63-4. Park PH, Sanz-Garcia C, Nagy LE. Adiponectin as an anti-fibrotic and anti-inflammatory adipokine in the liver. Curr Pathobiol Rep 2015; 3 (4): 243-52. Czaja AJ. Hepatic inflammation and progressive liver fibrosis in chronic liver disease. World J Gastroenterol 2014; 20 (10): 2515-32. Zaghloul MS, Said E, Suddek GM, Salem HA. Crocin attenuates lung inflammation and pulmonary vascular dysfunction in a rat model of bleomycin-induced pulmonary fibrosis. Life Sci 2019; 235 : 116794. Vepsalainen H, Nevalainen J, Fogelholm M, et al. Like parent, like child? Dietary resemblance in families. Int J Behav Nutr Phys Act 2018; 15 (1): 62. Table Table 1 Comparative Analysis of Diagnosis and Treatment Characteristics of Two Cases Comparing dimensions Case 1 Case 2 Age (years) 66 52 1 Time In July 2022 2 years ago Disease Atrial fibrillation Operation Radiofrequency ablation+left atrial appendage occlusion Radiofrequency ablation 2 Time In April 2023 1 years ago Disease Bloody pleural effusion Hemoptysis Operation Diagnostic anti tuberculosis Bronchial artery embolization 3 Time On May 9, 2023 On October 15, 2024 Operation Pulmonary vein CTA Result Reduced blood flow perfusion in the left pulmonary vein Left upper lobe pulmonary vein occlusion 4 Time On May 27th, 2023 On November 8, 2024 Operation Pulmonary vein stent implantation surgery 5 Time On August 25th, 2023 On December 13, 2024 Operation Pulmonary vein CTA Result Smooth blood flow reflux in the left upper and lower pulmonary veins Smooth blood flow reflux in the left upper pulmonary veins Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 20 Feb, 2026 Reviews received at journal 03 Jun, 2025 Reviews received at journal 02 Jun, 2025 Reviews received at journal 29 May, 2025 Reviewers agreed at journal 26 May, 2025 Reviews received at journal 25 May, 2025 Reviewers agreed at journal 21 May, 2025 Reviewers agreed at journal 21 May, 2025 Reviewers agreed at journal 18 May, 2025 Reviewers invited by journal 14 May, 2025 Editor assigned by journal 29 Apr, 2025 Editor invited by journal 25 Apr, 2025 Submission checks completed at journal 25 Apr, 2025 First submitted to journal 25 Apr, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6433927","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":456649525,"identity":"365c8f1b-8895-4cd1-a90d-dc3cad795025","order_by":0,"name":"HongJun Zhang","email":"","orcid":"","institution":"Xi'an Chest Hospital","correspondingAuthor":false,"prefix":"","firstName":"HongJun","middleName":"","lastName":"Zhang","suffix":""},{"id":456649526,"identity":"488bd9d6-32a3-4aab-a670-6edeaaf63d89","order_by":1,"name":"TianTian Ma","email":"","orcid":"","institution":"Xi'an Chest Hospital","correspondingAuthor":false,"prefix":"","firstName":"TianTian","middleName":"","lastName":"Ma","suffix":""},{"id":456649527,"identity":"de259e58-b993-4b4b-b705-357c25aa8103","order_by":2,"name":"Xing Gu","email":"","orcid":"","institution":"Xi'an Chest Hospital","correspondingAuthor":false,"prefix":"","firstName":"Xing","middleName":"","lastName":"Gu","suffix":""},{"id":456649528,"identity":"8af3daa4-fd9a-4b74-9a12-4b04163ea909","order_by":3,"name":"Jian LI","email":"","orcid":"","institution":"Xi'an Chest Hospital","correspondingAuthor":false,"prefix":"","firstName":"Jian","middleName":"","lastName":"LI","suffix":""},{"id":456649533,"identity":"1386b922-4e72-48c2-822e-e1981b7a63c9","order_by":4,"name":"Xiaoyan Zhang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABEElEQVRIiWNgGAWjYDACZihtACI+/rORY2NvP0C8FsYZbGnGfDxnEoizDaSFmYftcOI8CQcD/CqPMz98zFNzx96c/ezhlzN40tLbJBgSGH5UbMOpRbKZzdiY59gzZsuevDSLDxI2uW3SjQcYe87cxqmFn5nBTBroHjaDAzlmhjMM0nLbZA4kMDO24dbCxsz+TZrn32Eeg/NvzIx5Eg6ns0kkGODVws/MYybN23ZYwuBGjvFjngOHEwhqkWzmKTac23fYwODGGzPGmQ1phm3AQD6Izy8G549vfPDm22F7g/M5xh8+NtjIy7e3H3zwowK3FhBg4oH6SwImcgCveiBg/AGhmT8QUjkKRsEoGAUjEwAA2YpWuSb5ld8AAAAASUVORK5CYII=","orcid":"","institution":"Xi'an Chest Hospital","correspondingAuthor":true,"prefix":"","firstName":"Xiaoyan","middleName":"","lastName":"Zhang","suffix":""}],"badges":[],"createdAt":"2025-04-12 10:23:13","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6433927/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6433927/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":83039390,"identity":"842c7156-033b-4cf5-b77d-0f97985fc9ac","added_by":"auto","created_at":"2025-05-19 10:37:19","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":96261,"visible":true,"origin":"","legend":"\u003cp\u003eA. The diagnosis and treatment process of Case 1. \u0026nbsp;B. The diagnosis and treatment process of Case 2.\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6433927/v1/01115edfbe52c0135ad1290f.jpg"},{"id":83039391,"identity":"efd805fa-f031-48cb-b520-f72d8b197e10","added_by":"auto","created_at":"2025-05-19 10:37:19","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":200833,"visible":true,"origin":"","legend":"\u003cp\u003eChest CT scan of Case 1 on May 9, 2023: A. Pulmonary vein CTA shows a significant decrease in blood flow perfusion in the left pulmonary vein compared to the right (red arrow). B. Left atrial appendage occluder (red arrow). C. A small amount of pleural effusion on the left side. D. On August 25, 2023, Case 1 underwent a follow-up pulmonary vein CTA, which showed that the position of the left upper and lower pulmonary vein stent was good (red arrow). Case 2 chest CTA examination on October 15, 2024: E and G left upper pulmonary vein occlusion. Case 2 chest CTA examination on December 13, 2024: A tubular dense shadow was observed in the left upper pulmonary vein of F and H.\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6433927/v1/b821a7c05865b8f7f145e94f.jpg"},{"id":83042813,"identity":"c9b1506c-cc58-42b6-829f-b2e1fbe48279","added_by":"auto","created_at":"2025-05-19 11:01:23","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":657714,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6433927/v1/f23d112d-6b15-4cbe-a47e-b60b057b6a62.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Hemoptysis and Bloody Pleural Effusion in Atrial Fibrillation Patients Post-Radiofrequency Ablation: two Case Report and Mechanistic Discussion","fulltext":[{"header":"Introduction","content":"\u003cp\u003eCurrent medical research focuses on the electrophysiological mechanisms of atrial fibrillation (AF). AF is the most common clinical arrhythmia, marked by chaotic and disorganized atrial electrical activity, resulting in irregular atrial contractions\u003csup\u003e1\u003c/sup\u003e. Recently, the widespread use of radiofrequency ablation has complicated AF management, especially with the emergence of pulmonary vein stenosis (PVS) and postoperative pulmonary vein occlusion, both of which have drawn significant attention. PVS is regarded as one of the most serious complications after AF radiofrequency ablation, significantly affecting patients' quality of life\u003csup\u003e2\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eDespite numerous studies on the electrophysiological mechanisms of AF, significant gaps remain in understanding how PVS occurs. Research shows that AF onset is linked to several electrophysiological factors. These include increased atrial automaticity, reentrant excitation, and abnormal electrical conduction\u003csup\u003e3\u003c/sup\u003e. Furthermore, the persistent presence of AF may lead to atrial tissue remodeling, exacerbating the occurrence of electrophysiological abnormalities\u003csup\u003e4\u003c/sup\u003e. Therefore, a thorough investigation of the relationship between the electrophysiological mechanisms of AF and PVS occurrence will provide a vital theoretical basis for clinical research. Currently, treatment methods for PVS mainly include interventional therapy and surgical procedures. However, most existing studies are small-scale and retrospective, lacking systematic large-scale prospective research to assess the efficacy and safety of various treatment options\u003csup\u003e5\u003c/sup\u003e. Thus, further research into the pathophysiological mechanisms of PVS and its treatment methods is still needed.\u003c/p\u003e\n\u003cp\u003eThis study reviews two patients who developed post-ventricular tachycardia syndrome (PVS) after undergoing radiofrequency ablation for atrial fibrillation (AF). It analyzes their clinical manifestations and treatment outcomes. We will examine how effective percutaneous pulmonary vein stenting is in alleviating patient symptoms, using detailed case descriptions.The research methods involve case analysis and a literature review, aiming to provide new insights for the clinical management of atrial fibrillation patients and establish a theoretical foundation for future research.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003e1. Case 1\u003c/p\u003e\n\u003cp\u003e1.1 Demographics: 66-year-old male, teacher.\u003c/p\u003e\n\u003cp\u003e1.2 Chief complaint: Left-sided chest pain for over 2 months.\u003c/p\u003e\n\u003cp\u003e1.3 Medical history: Sudden onset of left chest pain without obvious triggers over 2 months ago, no radiation of pain, symptoms alleviated with rest. Presented at a local hospital, a chest CT showed some patchy areas of increased density in the left upper lobe and a small amount of left pleural effusion. T-SPOT: positive. The cause was unclear after examination, and the patient was treated for tuberculosis for a month, with no significant relief of chest pain. Pulmonary vein CTA showed reduced blood flow perfusion in the left pulmonary vein.\u003c/p\u003e\n\u003cp\u003e1.4 Treatment history (Figure 1 A): 40 years ago underwent surgical repair for atrial septal defect; persistent AF developed in July 2022, underwent AF radiofrequency ablation + left atrial appendage occlusion; in April 2023, unexplained hemorrhagic pleural effusion occurred, underwent diagnostic anti-tuberculosis treatment; on May 9, 2023, pulmonary vein CTA showed reduced blood flow perfusion in the left pulmonary vein (Figure 2A), left atrial appendage occluder (Figure 2B), and a small amount of left pleural effusion (Figure 2C); on May 27, 2023, underwent percutaneous pulmonary vein stenting, postoperative angiography showed unobstructed flow in the left upper and lower pulmonary veins; on August 25, 2023, follow-up pulmonary vein CTA showed good positioning of the left upper and lower pulmonary vein stents, with unobstructed blood flow (Figure 2D).\u003c/p\u003e\n\u003cp\u003e1.5 Diagnostic challenges: Chest CT and pleural ultrasound were performed due to left-sided chest pain, revealing a small amount of left pleural effusion. Closed drainage of the pleural cavity yielded red, turbid effusion, specific gravity 1.018, Lieberman test positive, white blood cell count 2128×10^6/L, with lymphocytes accounting for 85% and neutrophils for 15%. T-SPOT: positive. The pleural effusion was likely exudative. Among the most common exudative pleural effusions clinically, malignant pleural effusion was excluded, and diagnostic anti-tuberculosis treatment was given for over a month, with no significant relief of chest pain and no disappearance of pleural effusion. Only after performing pulmonary vein CTA was reduced blood flow perfusion in the left pulmonary vein discovered.\u003c/p\u003e\n\u003cp\u003e1.6 Treatment plan: On May 27, 2023, underwent percutaneous pulmonary vein stenting. Routine disinfection and draping were performed, and after local anesthesia, successful puncture of the left and right femoral veins was achieved, followed by the placement of a vascular sheath. Pulmonary vein angiography indicated severe stenosis (98%) of the left upper pulmonary vein, with occlusion of the left lower pulmonary vein. A catheter was advanced from the inferior vena cava to the right atrium, puncturing the interatrial septum to the left atrium, and a guidewire was sent into the left upper pulmonary vein. A 4mm balloon was used to dilate the left upper pulmonary vein, followed by the implantation of a 10*19mm stent, with angiography showing unobstructed flow in the left upper pulmonary vein. Attempts were made to open the left lower pulmonary vein; after the guidewire passed through the left lower pulmonary vein, a 3.4mm balloon was used for dilation, and a 10*19mm stent was implanted after the catheter passed through the stenosis, with angiography showing unobstructed flow in the left lower pulmonary vein.\u003c/p\u003e\n\u003cp\u003e1.7 Outcome: Postoperatively, the patient's chest pain and pleural effusion disappeared. Three months later, follow-up showed stable condition, and pulmonary vein CTA indicated good positioning of the left upper and lower pulmonary vein stents, with unobstructed blood flow (Figure 2D).\u003c/p\u003e\n\u003cp\u003e2. Case 2\u003c/p\u003e\n\u003cp\u003e2.1 Demographics: 52-year-old male, employee.\u003c/p\u003e\n\u003cp\u003e2.2 Chief complaint: Recurrent coughing up blood for over 1 year.\u003c/p\u003e\n\u003cp\u003e2.3 Medical history: Coughing up blood occurred over 1 year ago, with two previous bronchial artery embolization procedures for hemostatic treatment. On October 8, 2024, after a cold, coughing up blood recurred, initially with blood-streaked sputum, accompanied by chest tightness and shortness of breath, occasional cough and sputum production, with poor response to hemostatic medication. On October 15, 2024, massive coughing up blood occurred, approximately 200ml, bright red. Emergency hospitalization followed.\u003c/p\u003e\n\u003cp\u003e2.4 Treatment history (Figure 1B): History of AF for over 2 years, previously underwent radiofrequency ablation treatment three times; history of bronchiectasis for over 1 year, with two previous bronchial artery embolization procedures for coughing up blood; on October 8, 2024, blood-streaked sputum occurred; on October 15, 2024, massive coughing up blood occurred, approximately 200ml; chest CTA examination: left upper pulmonary vein occlusion (Figure 2 E, G). On October 24, 2024, DSA showed occlusion of the left upper pulmonary vein with significant collateral vessel proliferation and tortuosity; attempts to open the left upper pulmonary vein were unsuccessful; considering coughing up blood originated from the left upper pulmonary artery, a spring coil embolization was performed; on November 9, 2024, underwent percutaneous left upper pulmonary vein stenting, with postoperative angiography showing unobstructed flow in the left upper pulmonary vein; on December 13, 2024, follow-up chest CTA showed tubular dense shadow in the left pulmonary vein trunk (Figure 2 F, H).\u003c/p\u003e\n\u003cp\u003e2.5 Diagnostic challenges: The patient experienced recurrent coughing up blood, stopping after multiple bronchial artery and left upper pulmonary artery embolization procedures, but then recurring. Ultimately, percutaneous left upper pulmonary vein stenting was performed, resulting in complete resolution of coughing up blood symptoms.\u003c/p\u003e\n\u003cp\u003e2.6 Treatment plan: On November 9, 2024, underwent percutaneous pulmonary vein stenting. The patient was placed in a supine position, with routine disinfection and draping of the surgical area, and local anesthesia with 2% lidocaine was administered. A percutaneous puncture of the left and right femoral veins was successfully performed using an 18G puncture needle, followed by the placement of a 5F vascular sheath. Using a super slippery guidewire, left upper pulmonary artery angiography was performed, and DSA showed occlusion of the left upper pulmonary vein. Significant collateral vessels were noted, with proliferation and tortuosity. After exchanging the guidewire, a sheath for interatrial septum puncture (minimally invasive TNM7118) was placed, and an interatrial septum puncture needle was sent in to perform the puncture. After successfully entering the left atrium, a guidewire (Abbott) was used to guide the catheter through the interatrial septum, successfully opening the left upper pulmonary vein. A PTA balloon dilation catheter was sent in for dilation, and follow-up angiography showed blood flow through, though still narrowed. A peripheral stent (19*130) was sent in via the guidewire, and follow-up angiography showed the stent was well placed, with unobstructed blood flow and no stenosis.\u003c/p\u003e\n\u003cp\u003e2.7 Outcome: Postoperatively, the patient's coughing up blood symptoms disappeared. One month later, follow-up showed stable condition, and pulmonary vein CTA indicated good positioning of the left upper pulmonary vein stent, with unobstructed blood flow.\u003c/p\u003e\n\u003cp\u003e3. Comparative analysis (see Table 1):\u003c/p\u003e\n\u003cp\u003e3.1 Similarities: Both cases developed pulmonary vein stenosis or occlusion after AF radiofrequency ablation.\u003c/p\u003e\n\u003cp\u003e3.3 Differences: Case 1 presented with chest pain and bloody pleural effusion, while Case 2 presented with recurrent coughing up blood.\u003c/p\u003e\n\u003cp\u003e3.4 Treatment effect: Pulmonary vein stenting relieved pulmonary vein stenosis and occlusion, leading to rapid symptom resolution and good treatment outcomes.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn contemporary medical research, atrial fibrillation (AF) is the most common arrhythmia, and its pathological mechanisms are a key focus of academic interest. Several factors contribute to the occurrence of AF. These include the electrophysiological characteristics of the atrium, structural abnormalities, and the influence of the autonomic nervous system\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. The complexity of these mechanisms indicates that the development of AF is not yet fully understood, particularly in relation to pulmonary vein stenosis (PVS). Pulmonary vein stenosis (PVS) is a common complication that can occur after radiofrequency ablation for AF, and it may lead to severe clinical symptoms, including chest pain, hemoptysis, and dyspnea\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. Therefore, gaining a deeper understanding of the electrophysiological mechanisms of AF and their relationship with pulmonary vein stenosis is essential for enhancing the clinical management of affected patients.\u003c/p\u003e \u003cp\u003eThis study reviews two cases to analyze the clinical manifestations and treatment outcomes of pulmonary vein stenosis following AF radiofrequency ablation. Case 1 presents with chest pain, while Case 2 exhibits bloody pleural effusion and recurrent hemoptysis, both occurring after AF ablation. Percutaneous pulmonary vein stenting significantly improved the patients' symptoms and restored blood flow. This finding offers new insights into treating pulmonary vein stenosis and highlights the need for individualized treatment plans\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe development of pulmonary vein stenosis (PVS) after AF ablation is linked to various pathophysiological mechanisms, which contribute to the complexity of associated symptoms. The pathophysiological mechanisms of pulmonary vein stenosis and their clinical manifestations include RF energy injury, local inflammatory responses, and hemodynamic changes. This study explores the mechanisms underlying symptoms like chest pain, bloody pleural effusion, and hemoptysis. Additionally, this paper will examine changes in clinical manifestations during various postoperative time intervals, offering a theoretical basis for clinical monitoring and early intervention\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe occurrence of chest pain is mainly related to hemodynamic changes and local ischemia caused by pulmonary vein stenosis. Existing research shows that pulmonary vein stenosis can lead to insufficient microcirculation perfusion\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. This insufficiency results in local hypoxia, which stimulates pain receptors and causes ischemic pain. Furthermore, pulmonary congestion and interstitial edema can also affect the pleural space, elevating pleural pressure and worsening chest pain. In severe cases of pulmonary vein stenosis, the opening of pulmonary vein-bronchial artery collaterals may occur, causing turbulent blood flow and further aggravating pain\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eBloody pleural effusion is strongly associated with pulmonary venous hypertension and vascular injury. Pulmonary venous hypertension increases the filtration pressure of capillaries. This pressure can exceed the lymphatic system's ability to return fluid, causing protein-rich fluid and red blood cells to leak into the pleural cavity and form effusions\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e. During the ablation procedure, thermal injury from RF energy may directly damage the subpleural vessels, making the vessel walls more fragile and promoting the formation of bloody effusions. Additionally, local inflammatory responses can increase the permeability of pleural vessels by releasing pro-inflammatory factors, which worsens the leakage of bloody fluid\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eCoughing up blood is mainly linked to pulmonary venous hypertension and the rupture of new blood vessels. Pulmonary venous hypertension can cause blood to flow backward through the bronchial veins. This leads to swelling and rupture of these veins, which results in coughing up blood\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. Additionally, the formation of new blood vessels in areas with chronic blood supply issues can occur. These new vessels are often imperfect and may rupture when a person coughs or experiences pressure changes, worsening the bleeding\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. In severe cases of stenosis, a complete blockage of the pulmonary vein can cause lung tissue death, which may lead to the release of dead tissue and result in bleeding\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThese symptoms are closely linked to the progression of the disease. During the acute phase, patients often experience more severe chest pain and bloody pleural effusion, mainly due to vascular injury and inflammation\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e. In the chronic phase, as pulmonary veins develop fibrosis and experience hemodynamic changes, hemoptysis and worsening dyspnea become more noticeable, suggesting that patient monitoring and management should be adjusted based on the disease progression\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. Thus, the various pathophysiological mechanisms that cause pulmonary vein stenosis after atrial fibrillation (AF) ablation lead to a range of clinical symptoms. This variability necessitates a thorough assessment of symptoms to enable early intervention and improve patient outcomes.\u003c/p\u003e \u003cp\u003eAdditionally, our detailed analysis of the two cases shows that percutaneous pulmonary vein stenting effectively improves patient symptoms. In Case 1, the patient had severe chest pain and bloody pleural effusion, both of which improved after the stenting procedure. In Case 2, the patient experienced recurrent hemoptysis, which completely resolved following stenting. These results align with previous studies, demonstrating that pulmonary vein stenting can effectively alleviate symptoms caused by pulmonary vein stenosis. This finding also offers new insights for clinical treatment strategies\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. This new finding highlights the importance of considering pathophysiological mechanisms in managing patients with atrial fibrillation (AF) to create personalized treatment plans.\u003c/p\u003e \u003cp\u003eWhile the results of this study are clinically significant, there are still limitations. First, the sample size is small, analyzing only two cases, which may limit how broadly the results can be applied. Additionally, because this study is a retrospective analysis, potential biases cannot be fully controlled. Future research should use larger-scale prospective designs. This will help comprehensively evaluate the long-term effects and safety of percutaneous pulmonary vein stenting. Furthermore, exploring early identification and intervention strategies for pathophysiological mechanisms is a crucial direction for future research\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIn summary, this study shows that percutaneous pulmonary vein stenting works well through case analysis of two patients with pulmonary vein stenosis or occlusion after AF radiofrequency ablation. Although the study has limitations, such as a small sample size and short follow-up time, the results indicate that this treatment can effectively alleviate symptoms and improve pulmonary vein blood flow. This finding provides insights into clinical treatment strategies, emphasizing the importance of individualized approaches. Future research should prioritize assessing long-term effects to enhance the clinical value of this treatment.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eRRAST - Right-sided Pulmonary Arterial Stenosis\u003c/p\u003e\n\u003cp\u003ePV - Pulmonary Vein\u003c/p\u003e\n\u003cp\u003ePV Stenting - Pulmonary Vein Stenting\u003c/p\u003e\n\u003cp\u003ePulmonary Artery - Pulmonary Artery\u003c/p\u003e\n\u003cp\u003eAF - Atrial Fibrillation\u003c/p\u003e\n\u003cp\u003eRTV - Right ventricular volume\u003c/p\u003e\n\u003cp\u003eLVEF - Left ventricular ejection fraction\u003c/p\u003e\n\u003cp\u003eECMO - Extracorporeal Membrane Oxygenation\u003c/p\u003e\n\u003cp\u003eRRAST - Right-sided Pulmonary Arterial Stenosis\u003c/p\u003e\n\u003cp\u003eRV - Right ventricle\u003c/p\u003e\n\u003cp\u003eLA - Left anterior descending coronary artery\u003c/p\u003e\n\u003cp\u003eLAD - Left anterior descending coronary artery\u003c/p\u003e\n\u003cp\u003eSST - Segmental Sumission Therapy\u003c/p\u003e\n\u003cp\u003ePV - Pulmonary Vein\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate\u003c/p\u003e\n\u003cp\u003eDue to the retrospective nature of this study, we determined that seeking approval from the ethics committee (EC) was not necessary. We have implemented strict measures to protect patient confidentiality by omitting all identifiable information in the manuscript. we believe that anonymizing the patient's data adequately addresses potential privacy concerns.\u003c/p\u003e\n\u003cp\u003e●\u0026nbsp;Consent for publication\u003c/p\u003e\n\u003cp\u003eThe patient's written informed consent has been obtained for publication.\u003c/p\u003e\n\u003cp\u003e●\u0026nbsp;Availability of data and materials\u003c/p\u003e\n\u003cp\u003eThe data presented in this study are available on reasonable request from the first author.\u003c/p\u003e\n\u003cp\u003e●\u0026nbsp;Competing Interests\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e●\u0026nbsp;Funding\u003c/p\u003e\n\u003cp\u003eThis work was supported by grants from Xi'an Science and Technology Plan Project (2022JH-YBYJ-0157).\u003c/p\u003e\n\u003cp\u003e●\u0026nbsp;Authors' contributions\u003c/p\u003e\n\u003cp\u003eHongJun Zhang: Contributed to data acquisition, clinical analysis, manuscript drafting, and critical revision.\u003c/p\u003e\n\u003cp\u003eTianTian Ma: Participated in case analysis, literature review, and manuscript preparation.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Xing Gu: Assisted in clinical data interpretation and manuscript editing.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eJiAn LI: Performed interventional procedures (pulmonary vein stenting) and contributed to technical analysis.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eXiaoYan Zhang: Supervised the study, conceptualized the research, critically revised the manuscript, and approved the final version as the corresponding author. All authors reviewed and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e●\u0026nbsp;Acknowledgements\u003c/p\u003e\n\u003cp\u003eWe extend our sincere gratitude to the patients involved in this study for their consent to share clinical data and for their trust in our medical team. We acknowledge the collaborative efforts of the interventional radiology department at Xi'an Chest Hospital for their expertise in performing pulmonary vein stenting procedures. Special thanks to our nursing staff and clinical colleagues for their diligent patient care and data collection support. We also appreciate the constructive feedback from peer reviewers, which significantly strengthened the manuscript. This work was facilitated by the clinical research infrastructure of Xi'an Chest Hospital, and we remain indebted to our institution for fostering an environment conducive to interdisciplinary collaboration.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAslan O, Guneri S. [Electrophysiological mechanisms of atrial fibrillation]. \u003cem\u003eAnadolu Kardiyol Derg\u003c/em\u003e 2002; \u003cstrong\u003e2\u003c/strong\u003e(3): 244-52.\u003c/li\u003e\n\u003cli\u003ePan X, Wang C, Zhang Y, Wu W, Fang W. [Pulmonary vein stenting for the treatment of severe pulmonary vein stenosis after catheter ablation of atrial fibrillation]. \u003cem\u003eZhonghua Xin Xue Guan Bing Za Zhi\u003c/em\u003e 2014; \u003cstrong\u003e42\u003c/strong\u003e(10): 827-30.\u003c/li\u003e\n\u003cli\u003eBrugada J. [Electrophysiologic mechanisms of atrial fibrillation]. \u003cem\u003eRev Esp Cardiol\u003c/em\u003e 1996; \u003cstrong\u003e49 Suppl 2\u003c/strong\u003e: 8-12.\u003c/li\u003e\n\u003cli\u003eDelise P. [Electrophysiological mechanisms of atrial tachyarrhythmia]. \u003cem\u003eCardiologia\u003c/em\u003e 1991; \u003cstrong\u003e36\u003c/strong\u003e(8 Suppl): 11-5.\u003c/li\u003e\n\u003cli\u003eWong PC, Wang MA, Ng TJ, Akbarialiabad H, Murrell DF. Keratosis pilaris treatment paradigms: assessing effectiveness across modalities. \u003cem\u003eClin Exp Dermatol\u003c/em\u003e 2024; \u003cstrong\u003e49\u003c/strong\u003e(10): 1105-17.\u003c/li\u003e\n\u003cli\u003eXu L, Cui L, Hou J, et al. Clinical characteristics of patients with atrial fibrillation suffering from pulmonary vein stenosis after radiofrequency ablation. \u003cem\u003eJ Int Med Res\u003c/em\u003e 2020; \u003cstrong\u003e48\u003c/strong\u003e(3): 300060519881555.\u003c/li\u003e\n\u003cli\u003eChakraborty A, Paudel KR, Wang C, et al. Anti-inflammatory and anti-fibrotic effects of berberine-loaded liquid crystalline nanoparticles. \u003cem\u003eEXCLI J\u003c/em\u003e 2023; \u003cstrong\u003e22\u003c/strong\u003e: 1104-8.\u003c/li\u003e\n\u003cli\u003eTscheikuna J, Chvaychoo B, Naruman C, Maranetra N. Tranexamic acid in patients with hemoptysis. \u003cem\u003eJ Med Assoc Thai\u003c/em\u003e 2002; \u003cstrong\u003e85\u003c/strong\u003e(4): 399-404.\u003c/li\u003e\n\u003cli\u003eYin BY. [Bronchoscopic evaluation of 390 cases of hemoptysis without definite abnormality on the chest roentgenogram]. \u003cem\u003eZhonghua Jie He He Hu Xi Za Zhi\u003c/em\u003e 1990; \u003cstrong\u003e13\u003c/strong\u003e(1): 44-6, 63-4.\u003c/li\u003e\n\u003cli\u003ePark PH, Sanz-Garcia C, Nagy LE. Adiponectin as an anti-fibrotic and anti-inflammatory adipokine in the liver. \u003cem\u003eCurr Pathobiol Rep\u003c/em\u003e 2015; \u003cstrong\u003e3\u003c/strong\u003e(4): 243-52.\u003c/li\u003e\n\u003cli\u003eCzaja AJ. Hepatic inflammation and progressive liver fibrosis in chronic liver disease. \u003cem\u003eWorld J Gastroenterol\u003c/em\u003e 2014; \u003cstrong\u003e20\u003c/strong\u003e(10): 2515-32.\u003c/li\u003e\n\u003cli\u003eZaghloul MS, Said E, Suddek GM, Salem HA. Crocin attenuates lung inflammation and pulmonary vascular dysfunction in a rat model of bleomycin-induced pulmonary fibrosis. \u003cem\u003eLife Sci\u003c/em\u003e 2019; \u003cstrong\u003e235\u003c/strong\u003e: 116794.\u003c/li\u003e\n\u003cli\u003eVepsalainen H, Nevalainen J, Fogelholm M, et al. Like parent, like child? Dietary resemblance in families. \u003cem\u003eInt J Behav Nutr Phys Act\u003c/em\u003e 2018; \u003cstrong\u003e15\u003c/strong\u003e(1): 62.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Table","content":"\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 531px;\"\u003e\n \u003cp\u003eTable 1 \u0026nbsp;Comparative Analysis of Diagnosis and Treatment Characteristics of Two Cases\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eComparing dimensions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCase 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCase 2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e52\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTime\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eIn July 2022\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2 years ago\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDisease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eAtrial fibrillation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eOperation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRadiofrequency ablation+left atrial appendage occlusion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRadiofrequency ablation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTime\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;In April 2023\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1 years ago\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDisease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eBloody pleural effusion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHemoptysis\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eOperation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDiagnostic anti tuberculosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eBronchial artery embolization\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTime\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eOn May 9, 2023\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eOn October 15, 2024\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eOperation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003ePulmonary vein CTA\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eResult\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eReduced blood flow perfusion in the left pulmonary vein\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLeft upper lobe pulmonary vein occlusion\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTime\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eOn May 27th, 2023\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eOn November 8, 2024\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eOperation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003ePulmonary vein stent implantation surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTime\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eOn August 25th, 2023\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eOn December 13, 2024\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eOperation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003ePulmonary vein CTA\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eResult\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSmooth blood flow reflux in the left upper and lower pulmonary veins\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSmooth blood flow reflux in the left upper pulmonary veins\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-cardiovascular-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcar","sideBox":"Learn more about [BMC Cardiovascular Disorders](http://bmccardiovascdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bcar/default.aspx","title":"BMC Cardiovascular Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Atrial fibrillation, Radiofrequency Ablation, Pulmonary venous occlusion","lastPublishedDoi":"10.21203/rs.3.rs-6433927/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6433927/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eAtrial fibrillation (AF) is the most common arrhythmia in clinical practice. Developing pulmonary vein stenosis (PVS) after surgery can lead to serious symptoms, including chest pain, coughing up blood, and bloody pleural effusion. This study reviews two patients who developed PVS after AF radiofrequency ablation. It examines their clinical manifestations and the effectiveness of percutaneous pulmonary vein stenting. Through case analysis and literature review, we describe the clinical courses of two patients. Case 1, a 66-year-old male, presented with chest pain and bloody pleural effusion and showed significant improvement after pulmonary vein stenting. Case 2, a 52-year-old male, experienced recurrent coughing up blood, with symptoms that completely resolved after stenting. The findings suggest that percutaneous pulmonary vein stenting is very effective in alleviating symptoms associated with pulmonary vein stenosis. Despite the limited sample size, the results indicate that this treatment method offers an effective management option for AF patients. It highlights the need for individualized treatment and further exploration of the pathological mechanisms linking AF and PVS. Future larger-scale prospective studies are needed to verify the long-term safety and efficacy of this method to optimize clinical management strategies.\u003c/p\u003e","manuscriptTitle":"Hemoptysis and Bloody Pleural Effusion in Atrial Fibrillation Patients Post-Radiofrequency Ablation: two Case Report and Mechanistic Discussion","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-19 10:37:14","doi":"10.21203/rs.3.rs-6433927/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-02-20T13:43:21+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-03T10:12:25+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-02T09:24:35+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-29T05:50:14+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"38093472374721422144913965061684983979","date":"2025-05-26T14:26:39+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-25T20:53:42+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"119068038574375490147022033931110315952","date":"2025-05-21T08:23:09+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"297657005166032995552239013770946075049","date":"2025-05-21T07:16:44+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"326785789003661033328015144608585666198","date":"2025-05-18T11:22:52+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-05-14T15:50:26+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-04-29T10:56:29+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-04-25T15:42:48+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-04-25T12:55:54+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Cardiovascular Disorders","date":"2025-04-25T12:54:46+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-cardiovascular-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcar","sideBox":"Learn more about [BMC Cardiovascular Disorders](http://bmccardiovascdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bcar/default.aspx","title":"BMC Cardiovascular Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"718edd2a-7e7c-43fa-b8e6-0247b36e9e48","owner":[],"postedDate":"May 19th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-03-07T08:38:55+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-19 10:37:14","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6433927","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6433927","identity":"rs-6433927","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}