A 52-year-old male with AF underwent catheter ablation for two times. Eight months after the second maneuver for recurring AF, he presented with hemoptysis and exertional dyspnea. Computed tomography (CT) showed multiple consolidation in the left lung and ipsilateral pleural effusion (Fig. 1). Three-dimensional CT revealed severe stenosis of the left PV, and 2 months later, it was completely occluded (Fig. 2a). Since the symptoms grew more serious and transcatheter angioplasty seemed to be unfeasible due to little channels in ostia of PVs and has a certain risk of restenosis, surgical repair was planned. Under general anesthesia, cardiopulmonary bypass was initiated by aortobicaval cannulation via median sternotomy. A vent cannula was inserted into the left atrium through the right upper PV. After cross-clamping of the aorta and cardiac arrest with antegrade cardioplegia, the heart was manually retracted to the right. The left atrium was incised longitudinally from the apex of the LAA, and then the incision was separately extended towards the upper and lower PVs, respectively (Fig. 3a). The ostia of the PVs were completely occluded in the upper PV (Fig. 3b) and severely stenosed in the lower PV with fibrous scarring. The anterior wall of the stenotic or occluded lesions was dissected while the branches of the lower PV were relatively intact, and the upper PV was continuously stenosed to the peripheral branches. The incision was extended as peripherally as possible, but not to exceed the pericardium. The incised PVs and left atrium were covered with the incised LAA flap using a 5-0 monofilament running suture. The anastomosis line switched from the left atrium to the pericardium (Fig. 3c) and kept at least 5 mm away from the edge of the dissected PV walls to avoid direct suturing of venotomies. We also paid attention to the left phrenic nerve. The illustrated schema of the procedures is described in Fig. 4. These procedures were carried out under intermittent hypothermic circulatory arrest (28 °C) for prediction of the substantial bleeding from the collateral circulation such as the internal thoracic artery or bronchial artery. Maze procedure with cryoablation (Cryo ICE, AtriCure, OH, USA) was concurrently applied. After the surgery, the patient recovered sinus rhythm and was discharged without any complications. Enhanced CT demonstrated the patency of both left upper and lower PVs (Fig. 2b). Although the patient has maintained sinus rhythm afterwards, anticoagulant therapy was begun the following day after the surgery and has been proceeded with precautions against recurrence of AF and stenosis.