Paradoxical carbon dioxide embolism through an iatrogenic atrial septal defect after catheter ablation for atrial fibrillation during laparoscopic hepatectomy: two case reports and a brief review of the literature (with video).

Carbon dioxide (CO) embolism is an intraoperative complication during laparoscopic hepatectomy (Hx). Paradoxical CO embolism with right-to-left systemic shunting can cause cerebral infarction. Iatrogenic atrial septal defect (IASD) can occur after catheter ablation (CA) for atrial fibrillation (AF), and patients with IASD are at risk of paradoxical CO embolism. The present case report described two CO embolism cases during laparoscopic Hx after CA for Af (one is a paradoxical CO embolism). Intraoperative transesophageal echocardiography (TEE) is required for quick identification of CO embolism, and the procedure should be converted to laparotomy when paradoxical CO embolism occurs. Those patients were fortunately discharged without any postoperative morbidity. CA for AF may increase the risk of paradoxical CO embolism. The indication for laparoscopic Hx should be carefully judged based on the surgical procedure and the findings of preoperative TEE. Intraoperative TEE may be beneficial for early detection for quick identification of CO embolism, and the procedure should be converted to laparotomy when paradoxical CO embolism occurs.