Case Report
Postradiofrequency ablation inflammatory pseudotumor associated with pulmonary venoocclusive disease: case report and review of the literature

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Abstract

Radiofrequency ablation of pulmonary veins is a common therapeutic intervention for atrial fibrillation. Pulmonary vein stenosis and venoocclusive disease are recognized complications, but the spectrum of pathologies postablation have not been previously reviewed. A recent case at our hospital showed a left hilar soft tissue mass in association with superior pulmonary vein stenosis in a patient 4 years postablation. On resection, this proved to be an inflammatory pseudotumor composed of myofibroblasts in an organizing pneumonia-type pattern with adjacent dendriform ossifications. Pulmonary venoocclusive change was a prominent feature. Literature on the histopathology of postradiofrequency ablation complications is limited. The severity of vascular pathology appears to increase with the postablation interval. Although pulmonary vascular changes are the most common late finding, fibroinflammatory changes including pulmonary pseudotumor formation, attributable to thermal injury, should be considered in the differential diagnosis of these cases.

Introduction

Radiofrequency ablation of pulmonary veins is an increasingly common therapeutic intervention for medically refractory atrial fibrillation that targets the proximal myocardial tissue beyond the pulmonary vein ostia [1]. Pulmonary vein stenosis and subsequent pulmonary venoocclusive disease are recognized but uncommon complications of this procedure [2]. Associated pulmonary inflammatory pseudotumor formation necessitating surgical resection has not been previously reported.

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Materials and methods

Two surgical resections from our institution were reviewed by light microscopy, one of pseudotumor formation with associated pulmonary vein stenosis (current case). A literature search was performed for the following terms: “histology,” “pathology,” and “histopathology” each with “pulmonary vein radiofrequency ablation atrial fibrillation.” Pathologic features of the Massachusetts General Hospital cases were compared with those in existing reports.

Index case clinical history

A 66-year-old man with chronic obstructive pulmonary disease and hypertension had refractory atrial fibrillation that required radiofrequency ablation. The left upper, left middle, and right upper pulmonary veins were isolated and ablated. The procedure was complicated by hemopericardium and cardiac tamponade requiring emergency pericardiocentesis. He recovered and remained in sinus rhythm.

Four years later, he experienced the onset of hemoptysis that was small in volume but frequent, associated

Discussion

Pulmonary vein stenosis occurs in approximately 3% to 15% of patients following radiofrequency ablation for atrial fibrillation, but symptomatic pulmonary venoocclusive disease is rare [9]. Presenting symptoms include hemoptysis, dyspnea, and cough. The underlying pathophysiology is postobstruction venous congestion in most cases. The timing of symptom onset following ablation is variable, occurring in some patients years after the intervention [10], whereas others report symptoms immediately

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