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Targeted temperature management (TTM) is associated with corrected QT (QTc) prolongation and decrease in serum magnesium (Mg) levels that may lead to recurrent ventricular arrhythmia and poor neurological outcomes. We aimed to evaluate the association between QTc interval and Mg levels during TTM with neurological outcomes. We reviewed the electrocardiograms of 366 patients who underwent TTM during the induction, maintenance, and rewarming phase after cardiac arrest. We reviewed the association of change in QTc interval, and Mg levels with neurological outcomes. In total, 71.3% of the patients had a significant increase in QTc interval defined as >60 ms or any QTc >500 ms during TTM. Poor neurological outcome was associated with persistent prolongation of QTc after rewarming (507 vs. 483 ms, p  = 0.046) and higher Mg levels at presentation (2.08 ± 0.41 mg/dL, p  = 0.014). Supplemental Mg did not have any significant change in their QTc. Patients with prolonged QTc during TTM should be promptly evaluated for QTc-prolonging factors given its association with worse neurological outcomes. The inverse correlation between Mg levels and poor neurological outcomes deserves further investigation.

Intra-arterial injection of recreational substances and drugs is less well described in the literature. It carries a risk for hand ischemia and embolization to the hand digits and ultimately amputation.

Conscious sedation (CS) has been increasingly utilized in transcatheter aortic valve implantation (TAVI). We aim to compare safety, efficacy, efficiency, and direct cost outcomes of patients who underwent TAVI with general anesthesia (GA) to those with CS. Records for all adult patients undergoing transfemoral TAVI at our institution between February 2012 and September 2018 were retrospectively screened. Patients were grouped by anesthesia treatment (GA or CS) and propensity matched. Safety (in-hospital and 30-day mortality, in-hospital and 30-day stroke, cardiac arrest, need for permanent pacemaker, and composite bleed/vascular adverse events), efficacy (follow-up echocardiographic findings), efficiency (procedure duration, fluoroscopy time, radiation dose, intensive care unit (ICU) stay, hospital length-of-stay, and discharge to home), and direct cost outcomes were compared. A total of 589 patients met our inclusion criteria. Propensity matching yielded 154 GA patients and 154 CS patients. There were no differences in the safety outcomes of in-hospital or 30-day mortality, in-hospital or 30-day stroke, cardiac arrest, and need for permanent pacemaker between GA and CS groups. There was a significant reduction in composite bleeding/vascular events in the CS group (8.4% vs 19.5%, p < 0.01). There were no differences in the follow-up echocardiograms with respect to aortic valve area, left ventricular ejection fraction, and incidence of moderate or severe aortic regurgitation. The CS group had shorter procedural fluoroscopy times and radiation dose, shorter length-of-stay and ICU stay, with similar procedural duration. CS patients were more likely to be discharged to home (59.7% vs 74.7%, p < 0.01). Total direct costs for CS were decreased in almost every departmental category, with a mean 10.4% reduction in overall direct costs (p < 0.001). In conclusion, TAVI with CS is associated with less bleeding and vascular events, lower procedural radiation exposure, reduced length of hospitalization and ICU stay, and lower direct costs in comparison with TAVI with GA. These outcomes occur without sacrificing procedural efficacy or safety., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Left atrial dissection is an exceedingly rare complication of cardiac surgery, with an incidence of 0.16%-0.84%. We report the first case of interatrial dissection and hematoma in association with the MitraClip procedure. Hemodynamically stable patients can be managed conservatively, with echocardiographic imaging, often with resolution of the dissection over the course of weeks. Our patient remained hemodynamically stable and asymptomatic post operation; at 1-month follow-up, echocardiogram showed resolution of the interatrial septal dissection.

Periprocedural stroke related to transcatheter aortic valve replacement (TAVR) is associated with increased morbidity and mortality. Cerebral embolic protection using the Sentinel device (Claret Medical) has demonstrated reduced rates of stroke during TAVR. However, alternative access such as a transcarotid approach precludes the use of the Sentinel device. We report a case using cerebral embolic protection during a right transcarotid TAVR.

A 60-year-old male presented 12 months after CABG surgery with a large pulsatile sternal mass. CT scan of the chest demonstrated a pseudoaneurysm originating from the mid saphenous vein graft to the PDA measuring 7.7 x 7.2 x 6.0 cm. After a multidisciplinary consultation, a decision was made to place a Jostent GraftMaster to completely seal the communication of the extravasation.

Therapeutic hypothermia (TH) improves neurological outcomes after cardiac arrest by mitigating cerebral reperfusion injury. Serum magnesium (Mg) inhibits glutamate release, restores blood-brain barrier integrity, and decreases brain edema. The neuroprotective role of Mg in cardiac arrest patients undergoing TH is not well established. We analyzed 438 survivors of cardiac arrest who completed a TH protocol from 2008 through 2016. Multivariate and receiver operating characteristic (ROC) analyses examined the association between Mg supplementation and Mg levels before, during, and after TH with neurologic outcomes. Participants were 65.5 ± 15.9 years old, 47% received bystander cardiopulmonary resuscitation, and time to target temperature was 286 ± 196 minutes. Patients with favorable neurologic outcomes had lower Mg levels at presentation (2.1 mg/dL vs. 2.2 mg/dL, p = 0.010; OR [95% CI] = 0.531 [0.329-0.857]) and more frequently received Mg supplementation (39% vs. 25%, p = 0.009; OR [95% CI] = 1.936 [1.171-3.202]). Mg levels on presentation inversely correlated with favorable neurologic outcomes (r = -0.134, p = 0.036). Stratification of patients based on Mg levels demonstrated trends toward worse neurological outcomes at the extremes of the range, though sample sizes were small and the point estimate was not significant. ROC analysis showed no significant Mg level determining favorable outcomes. Mg levels at presentation inversely correlated with neurologic outcomes in cardiac arrest survivors undergoing TH. Intracellular shift and increased renal excretion of Mg may be responsible for the low Mg levels seen in some patients undergoing TH. Whether Mg supplementation could potentiate the beneficial effects of TH remains unclear and deserves further investigation.

Opinion Statement: Aortic regurgitation is a frequently encountered condition, in which traditional measurements of severity have proven to be of limited value in identifying those who would be best served by aortic valve replacement. Novel methods of assessing severity are vital, particularly as an entirely new paradigm of aortic regurgitation has surfaced, with the advent of transcatheter aortic valve replacement (TAVR), and the adverse events that are being observed with varying degrees of aortic regurgitation. With that in mind, a comprehensive assessment of aortic regurgitation should now include indexed left ventricular systolic volumes and a comprehensive assessment of right ventricular function, in addition to the quantitative measures that are currently recommended. Cardiac MRI also provides valuable information and should be strongly considered, particularly in challenging cases. The incremental value of additional echocardiographic parameters such as strain imaging, speckle tracking imaging, and tissue Doppler imaging remains unclear, and evidence for their utility is not, as yet, compelling. However, the field of aortic regurgitation assessment has been reinvigorated by the prevalence of paravalvular regurgitation post-TAVR, and many of the abovementioned parameters may need to be re-visited so that we can more accurately determine prognosis and risk stratify patients in a more reliable and evidence-based manner.

Many patients with left ventricular assist devices (LVAD) have implantable cardioverter defibrillators (ICDs) as part of the management of advanced heart failure. With increasing use and coexistence of these devices in patients with advanced cardiomyopathy, adverse interactions between these devices have been recognized. We herewith describe a rare adverse interaction of electromagnetic interference (EMI) between a third-generation, continuous-flow device (The HeartWare HVAD) and an ICD which resulted in the delivery of inappropriate ICD therapies. A schematic approach for the prevention and treatment of electromagnetic interference has also been described.