Introduction: In this case, we discuss the intraoperative risk of air cardioembolic stroke in patients with intra-cardiac shunts undergoing laparoscopic surgery due to CO 2 insufflation of the abdomen in conjunction with provoked right-to-left shunting from anesthesia. Case Presentation: 27-year-old Female with Down Syndrome and asymptomatic VSD presented with abdominal pain. CT Abdomen performed revealed Acute Cholecystitis and patient was admitted for urgent laparoscopic cholecystectomy. Cardiology was consulted for preoperative risk assessment. Echocardiogram recommended and redemonstrated known VSD with predominant left-to-right shunting and occasional flow reversal (right-to-left) at baseline. Upon discussion with Anesthesia, the concern arose for anesthesia induced flow reversal of the shunt with a risk of possible paradoxical air embolism from CO 2 insufflation during laparoscopy. This concern was presented to the General Surgery team for consideration of conversion of procedure to open cholecystectomy. Open cholecystectomy was performed without complications. Discussion/Conclusion: Laparoscopic surgery requires CO 2 insufflation of the abdomen to cause pneumoperitoneum (Fig 1A), following which a gas embolism can result (Fig 1B). Consequently, in the absence of a pre-existing cardiac defect, patients can develop a pulmonary embolism (Fig 1C). However, individuals with right-to-left intracardiac shunting (Fig 1D), or Eisenmenger Syndrome, confer the additional risk of cardioembolic stroke (Fig 1E). In the preoperative assessment, right-to-left shunting is easily identified by TTE and managed accordingly. However, less intuitively, it can also occur transiently from the intraoperative use of certain anesthesia medications such as Propafol, which is known to decrease SVR. Therefore, if the evaluating clinician is unaware of this mitigated risk, it may go undetected, the result of which can be fatal.

Arthropod and insect bites/stings have been associated with the development of Acute Coronary Syndrome (ACS) in prior case reports. In this systematic analysis, we review 57 reported cases of ACS in patients that were exposed to arthropods, bee stings or insect bites, and provide a summary of these findings in Table 1. We then discuss Kounis Syndrome Type 1 or Type 2 as the proposed mechanism by which myocardial ischemia develops in this subset of patients, and the implications of this diagnosis on management. Kounis Syndrome Type 1 develops due to mast cell activation and histamine release provoking vasospasms and inducing myocardia injury in the absence of underlying coronary artery disease, as demonstrated in Figure 1A. Kounis Syndrome Type 2 develops due to inflammation induced plaque rupture and subsequent thrombus formation, as demonstrated in Figure 1B. In general, Kounis Syndrome should be suspected in patient’s presenting with the appropriate exposure, an allergic or anaphylactic response and/or unremarkable coronary angiogram (specific to Type 1). Once suspected, the use of coronary artery vasodilators, antihistamines, steroids and possibly Epinephrine should be considered in management. In this review, it was discovered that approximately 50% of cases received management consistent with Kounis Syndrome (targeted to allergic/anaphylactic symptoms) with appropriate clinical response, yet only 12% received the formal diagnosis, indicating this condition is underdiagnosed. Furthermore, 40% of patients that underwent coronary angiogram did not have CAD, indicating a possible Type 1 (vasospastic) etiology of ACS that may benefit from more targeted therapy.

In this report, we present an incidental finding of a rare combination of an Aberrant Right Subclavian Artery (ARSA), or arteria lusoria, with right-sided aortic arch and atrial septal defect associated with extensive thrombosis and paradoxical embolism causing acute stroke in an octogenarian woman with COPD presenting with acute hypercapnic respiratory failure. We also discuss the various surgical approaches for management and conservative treatment alternatives in non-surgical candidates (as in this case). We believe that this is the first reported case of these combined rare anomalies in an asymptomatic patient to the best of our knowledge.