• David Velghe, Thomas Apers, Stefanie Devriendt, Ivo Deblier, Bart Hendriks, Rogier Nieuwendijk, and Peter Rogiers.
• 1Department of Anesthesia and Reanimation, ZNA Middelheim Hospital, Antwerpen, Belgium.2Department of Cardiothoracic Surgery, ZNA Middelheim Hospital, Antwerpen, Belgium.3Department of Critical Care, ZNA Middelheim Hospital, Antwerpen, Belgium.
• Crit. Care Med. 2017 Aug 1; 45 (8): e867-e871.

ObjectiveTo describe a case of an infected atriobronchial fistula as a late complication after pulmonary vein ablation, leading to septic air emboli and requiring urgent cardiac surgery.Data SourcesClinical observation.Study SelectionCase report.Data ExtractionRelevant clinical information. PubMed was searched for relevant literature.Data SynthesisGiven its high success and low complication rate, pulmonary vein isolation is expected to be increasingly performed worldwide. Despite its success, some of its rare complications are potentially devastating and are difficult to diagnose early. In this report, we present the case of a 32-year-old woman, who was readmitted to hospital 2 months after pulmonary vein ablation. The clinical picture resembled meningococcemia with spreading petechiae on legs and arms raising concern for Waterhouse-Friderichsen syndrome. Further echocardiographic investigation led to the discovery of massive amounts of intracardiac air which demanded urgent lung isolation and sternotomy. Intraoperatively a small infected left atrial perforation was oversewn and a fistula to the right main bronchus was closed by means of an autologous pericardial patch. One month later, still revalidating, she could be discharged home with only minor neurologic sequelae.ConclusionsClinicians should be aware of the dramatic complications of invasive antiarrhythmic procedures and their atypical and late presentations. Better preprocedural appreciation of cardiac wall thickness, early echocardiographic diagnosis, and swift referral for cardiac surgery might impact outcome dramatically.

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