Jonathan Michel

Full Recovery from a Potentially Lethal Dose of Mercuric Chloride

IntroductionMercuric chloride poisoning is rare yet potentially life-threatening. We report a case of poisoning with a potentially significant amount of mercuric chloride which responded to aggressive management.Case ReportA 19-year-old female presented to the Emergency Department with nausea, abdominal discomfort, vomiting of blood-stained fluid, and diarrhea following suicidal ingestion of 2–4xa0g of mercuric chloride powder. An abdominal radiograph showed radio-opaque material within the gastric antrum and the patient’s initial blood mercury concentration was 17.9xa0μmol/L (or 3.58xa0mg/L) at 3xa0h post-ingestion. Given the potential toxicity of inorganic mercury, the patient was admitted to the intensive care unit and chelation with dimercaprol was undertaken. Further clinical effects included mild hemodynamic instability, acidosis, hypokalemia, leukocytosis, and fever. The patient’s symptoms began to improve 48xa0h after admission and resolved fully within a week.DiscussionMercuric chloride has an estimated human fatal dose of between 1 and 4xa0g. Despite a reported ingestion of a potentially lethal dose and a high blood concentration, this patient experienced mild to moderate poisoning only and she responded to early and appropriate intervention. Mercuric chloride can produce a range of toxic effects including corrosive injury, severe gastrointestinal disturbances, acute renal failure, circulatory collapse, and eventual death. Treatment includes close observation and aggressive supportive care along with chelation, preferably with 2,3-dimercapto-1-propane sulfonate or 2,3-meso-dimercaptosuccinic acid.

Parallel suture technique with ProGlide: a novel method for management of vascular access during transcatheter aortic valve implantation (TAVI)

AIMSnThe aim of this study was to evaluate vascular complications using the parallel suture technique in patients receiving an Edwards SAPIEN XT (SXT) or SAPIEN S3 (S3) transcatheter heart valve (THV).nnnMETHODS AND RESULTSnTwo hundred consecutive patients with symptomatic severe aortic stenosis treated with TF-TAVI were included in this study where the parallel suture technique was applied for vascular access-site closure. This was achieved by placing the sutures medial and lateral to the puncture site. Vascular access-site complications were defined as vascular dissection, perforation, obstruction, arteriovenous fistula or pseudoaneurysms, and classified according to the Valve Academic Research Consortium-2 (VARC-2) criteria. Duplex sonography was performed routinely in every patient. In patients receiving the S3, the sheath to femoral and iliac artery ratio was significantly lower than in the SXT group, reflecting reduction in sheath sizes for S3. More endovascular interventions were required after SXT implantation as compared to S3 (4% versus 1%, p=0.02). This was due to vascular obstruction or device failure. Moreover, increased life-threatening, major bleedings, and pseudoaneurysms were found in the SXT group (6% versus 1%, p=0.06, 13% versus 3%, p=0.009, 7% versus 1%, p=0.03, respectively).nnnCONCLUSIONSnThe parallel suture technique using the ProGlide is associated with a low number of vascular complications, even when using larger sheath sizes.

Predictors of Need for Permanent Pacemaker Implantation and Conduction Abnormalities With a Novel Self-expanding Transcatheter Heart Valve

INTRODUCTION AND OBJECTIVESnThe incidence of permanent pacemaker implantation (PPI) and new conduction abnormalities (CA) with the ACURATE neo (Symetis S.A., Eclubens, Switzerland) has not been studied in detail. We aimed to analyze their predictors, evaluating patient- and device-related factors, including implantation depth and device-to-annulus ratio (DAR).nnnMETHODSnTwo analyses of a multicenter population were performed: new PPI in pacemaker-naive patients (n = 283), and PPI/new-CA in patients without prior CA or pacemaker (n = 232).nnnRESULTSnA new PPI was required in 9.9% of patients, who had a higher body mass index, higher rate of right bundle branch block and bradycardia. Neither implantation depth nor DAR differed in patients with PPI compared with those without. In the multivariable analysis neither DAR (OR, 1.010; 95%CI, 0.967-1.055; P = .7) nor implantation depth (OR, 0.972; 95%CI, 0.743-1.272; P = .8) predicted PPI. Only high body mass index, bradycardia and right bundle branch block persisted as independent predictors. PPI/new-onset CA occurred in 22.8% of patients and was associated with a higher logistic EuroSCORE. Neither implantation depth nor DAR differed in patients with PPI/new-CA vs those without (7.3 ± 1.9 vs 7.1 ± 1.5mm; P = .6 and 41.0 ± 7.9 vs 42.2 ± 10.1%; P = .4). The only predictor of PPI/new-CA was a higher logistic EuroSCORE (OR, 1.039; 95%CI, [1.008-1.071]; P = .013).nnnCONCLUSIONSnNew PPI and new-onset CA rates were low with the ACURATE neo. These were mainly influenced by patient characteristics and not by device-depending factors.

Outcomes Following Conservative Management of Spontaneous Coronary Artery Dissection.

Spontaneous coronary artery dissection (SCAD) is a rare but a serious cause of myocardial ischaemia and infarction that occurs most frequently in younger female patients. The management of this rare condition remains controversial. In this case series we describe the spectrum of outcomes observed following conservative management.

Multicenter Evaluation of Prosthesis Oversizing of the SAPIEN 3 Transcatheter Heart Valve. Impact on Device Failure and New Pacemaker Implantations

INTRODUCTION AND OBJECTIVESnA certain degree of prosthesis oversizing (OS) is recommended for the SAPIEN 3 to achieve device success. However, an increase in OS may increase permanent pacemaker implantation (PPI) rates. We therefore investigated the influence of OS on device failure and PPI.nnnMETHODSnA total of 804 patients were treated with SAPIEN 3 at 3 centers. Multislice computed tomography-derived OS was calculated and analyzed both as a continuous variable and categorized in 5% increments with -4% to 0% as reference.nnnRESULTSnDevice failure occurred in 8.8% of patients. Median OS was lower in patients with device failure vs those with device success (+4% vs +8%; P=.038). A nonlinear risk pattern was shown for OS with a significantly reduced device failure rate within 4% to +22% of OS. There was no case of paravalvular leakage II+ between +10% to +20% of OS. The overall PPI rate was 16.2% and the median OS was significantly larger in patients with PPI (PPI: +9% vs no PPI: +7%; P = .025), while implantation depth did not vary in patients with vs without PPI (6.9±1.7xa0mm vs 6.6±1.9xa0mm; P=.101). The risk of PPI increased with increasing OS and was highest in the 2 highest categories.nnnCONCLUSIONSnAn increase in OS reduces the risk for device failure but increases the risk for PPI. There was no ideal range of OS to minimize both device failure and PPI.

Bending the Rules in Transfemoral TAVI With the SAPIEN 3: Overcoming Severe Iliac Tortuosity

Whilst the worldwide uptake of transcatheter aortic valve implantation (TAVI) over the last 10 years has been dramatic, iliac tortuosity remains a potential barrier to the most commonly chosen access route via the femoral artery. We describe the challenges posed by severe iliac tortuosity during transfemoral TAVI and contrast a difficult procedure - at the limit of the capability of current device delivery technology - with a straightforward implantation. The use of pre-procedural multi-detector computed tomography to assess the vasculature and a bilateral stiff wire technique for managing iliofemoral tortuosity are discussed.