Feeling a Little Blue After Ablation: Iatrogenic Atrial Septal Defect With Right-to-Left Shunt Following Atrial Fibrillation Ablation.

Atrial fibrillation is the most common cardiac arrhythmia. Cardiac ablation is indicated for patients refractory to medical management. During the ablation process, a transseptal puncture is utilized to access and isolate the pulmonary veins, which results in a temporary iatrogenic atrial septal defect (iASD). Generation of an iASD is considered unavoidable and is a generally accepted risk due to high rates of spontaneous closure. Studies have shown that persisting iASD may occur in 5%-20% of patients for up to nine to 12 months after undergoing radiofrequency ablation and that spontaneous rates of closure are high in patients with normal intracardiac pressures. Patients with preexisting elevated right intracardiac pressures from pulmonary hypertension or other right-sided cardiac pathology are at an increased risk of complications from iASD. These increased pressures can lead to clinically significant hypoxemia from right-to-left shunting following a transseptal puncture. Intervention with closure is considered in high-risk settings such as right atrial or ventricular enlargement, right-to-left shunting with hypoxemia, and intraseptal defect greater than 8 mm. This case vignette describes a 67-year-old female who developed clinically significant right-to-left shunting intraoperatively from iASD with ongoing hypoxemia for several months but with spontaneous closure. We highlight this case as it demonstrates spontaneous closure in a high-risk iASD. We also provide a review of the literature on iASD after cardiac ablations.

Battery swallow-induced tracheoesophageal fistula in a pediatric patient.

Tracheoesophageal fistula (TEF) is an abnormal connection between the trachea and esophagus. Rare acquired TEF arises from trauma, caustic fluids ingestion, and iatrogenic injuries (ventilation, esophageal atresia repair, radiation, or tracheal/esophageal stents). We discuss the diagnosis, anesthetic management, and surgical correction of battery swallow-induced TEF, not previously reported in the pediatric anesthesia and otorhinolaryngology literatures.

Temporal Profile and Treatment of Purpureocillium lilacinum Keratitis Secondary to Herpes Zoster Reactivation Following Influenza Vaccination.

PURPOSE: To report a temporal profile of Purpureocillium lilacinum keratitis (PLK) secondary to immune dysfunction induced by the combination of reactivation of herpes zoster dermatitis and recent influenza vaccination that suggests a possible association, including successful medical management. METHODS: A 64-year-old contact lens wearer presented with left eye keratitis days after receiving an influenza vaccination and subsequent development of herpes zoster lesions on the flank. Patient was initially treated for bacterial keratitis with fortified antibiotics and oral valacyclovir for her concurrent zoster. Pharmacotherapy was changed to topical voriconazole after cultures were positive for Purpureocillium lilacinum. Topography and anterior segment OCT demonstrated scarring at multiple levels within the cornea with irregular astigmatism. A literature review was conducted to identify mechanisms that demonstrate a temporal link between influenza vaccination, herpes zoster reactivation, and fungal keratitis. RESULTS: After the conclusion of topical therapy, the central corneal infiltrate regressed and a partial light-blocking anterior stromal scar remained. Best corrected visual acuity improved from 20/400 to 20/25. CONCLUSION: Transient systemic immune dysregulation, secondary to influenza vaccination and reactivation of systemic herpetic disease, compounded by contact lens wear, may create a favorable environment for opportunistic fungal keratitis. This case highlights the importance of adequately assessing and treating for existing comorbidities in the successful treatment of mycotic keratitis.