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 (CO2) embolism is an intraoperative complication during laparoscopic hepatectomy (Hx). Paradoxical CO2 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 CO2 embolism. The present case report described two CO2 embolism cases during laparoscopic Hx after CA for Af (one is a paradoxical CO2 embolism). Intraoperative transesophageal echocardiography (TEE) is required for quick identification of CO2 embolism, and the procedure should be converted to laparotomy when paradoxical CO2 embolism occurs. Those patients were fortunately discharged without any postoperative morbidity. CA for AF may increase the risk of paradoxical CO2 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 CO2 embolism, and the procedure should be converted to laparotomy when paradoxical CO2 embolism occurs.