Percutaneous left atrial appendage closure is a common alternative for stroke prevention in patients with non-valvular atrial fibrillation. There are several devices available on the market, each with its own advantages and disadvantages. One of the most feared complications is device embolization, which happens with an incidence of approximately 2%. We present a case of embolized Amulet which was successfully retrieved from the left ventricle using a mediastinoscope and transesophageal echocardiographic guidance.

Alpha-pyrrolidinovalerophenone (α-PVP), known on the street simply as “flakka”, is one of a number of second-generation synthetic stimulants being used recreationally. Being a relatively new drug, a literature search provided little information. There are currently only 3 case reports of sudden cardiac death,1Eiden C. Mathieu O. Cathala P. et al.Toxicity and death following recreational use of 2-pyrrolidino valerophenone.Clin Toxicol (Phila). 2013; 51: 899-903Crossref PubMed Scopus (39) Google Scholar, 2Nagai H. Saka K. Nakajima M. et al.Sudden death after sustained restraint following self-administration of the designer drug α-pyrrolidinovalerophenone.Int J Cardiol. 2014; 172: 263-265Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar, 3Sykutera M. Cychowska M. Bloch-Boguslawska E. A fatal case of pentedrone and alpha-pyrrolidinovalerophenone poisoning.J Anal Toxicol. 2015; 39: 324-329Crossref PubMed Scopus (56) Google Scholar but we expect this to change as providers become more aware of this deadly drug and recognition of flakka-induced cardiac failure improves. We recently cared for a unique case of flakka-induced ST-elevation myocardial infarction (STEMI) with multiple intracardiac thrombi. The patient was a 41-year-old female with no significant medical history who presented to the emergency room with an anterior STEMI. She reported partying with friends prior to presentation, which included the ingestion of α-PVP. Cardiac catheterization revealed a proximal thrombus totally occluding the left anterior descending artery, which was treated successfully with aspiration thrombectomy. There was 80%-to-90% stenosis of the proximal ramus intermedius, which was treated with a bare metal stent. She also was found to have a left ventricular apical thrombus, which was treated by thrombectomy. She would go on to require intubation for respiratory failure secondary to pulmonary edema. Following a lengthy hospitalization, in which a full thrombophilia workup was negative, she eventually was discharged home. As a cathinone derivative, α-PVP is similar chemically to the drugs commonly referred to as “bath salts.” Despite its chemical similarities, it is distinct from other street drugs, so urine toxicology screens will be negative for cocaine, amphetamines, and so on. α-PVP has been implicated in the death of more than 40 people in Broward County, Florida over the past year.4Ovalle D, Weaver J: South Florida’s source for synthetic drugs: The China pipeline. Available at: 〈http://www.miamiherald.com/news/local/crime/article35417625.html〉. Accessed July 7, 2016Google Scholar Mechanistically, α-PVP increases the release of dopamine from dopaminergic neurons within the mesolimbic cortex via dopamine transporters and also inhibits its reuptake.5Kolanos R. Sakloth F. Jain A.D. et al.Structural modification of the designer stimulant α-pyrrolidinovalerophenone (α-PVP) influences potency at dopamine transporters.ACS Chem Neurosci. 2015; 6: 1726-1731Crossref PubMed Scopus (51) Google Scholar Similarly, α-PVP inhibits the reuptake of norepinephrine and, to a lesser extent, serotonin. The speed of onset occurs more quickly than methamphetamine and the duration of action is longer.6Marusich J.A. Antonazzo K.R. Wiley J.L. et al.Pharmacology of novel synthetic stimulants structurally related to the “bath salts” constituent 3,4-methylenedioxypyrovalerone (MDPV).Neuropharmacology. 2014; 87: 206-213Crossref PubMed Scopus (160) Google Scholar, 7Kaizaki A. Tanaka S. Numazawa S. New recreational drug 1-phenyl-2-(1-pyrrolidinyl)-1-pentanone (alpha-PVP) activates central nervous system via dopaminergic neuron.J Toxicol Sci. 2014; 39: 1-6Crossref PubMed Scopus (50) Google Scholar It also is more potent than cocaine or methamphetamine, making it extremely addictive. Clinically, it produces an “excited delirium” characterized by hallucinations, aggression, agitation, and frequently violence or self-harm. Physiologically, the results are tachycardia, hypertension, pulmonary congestion, extreme hyperthermia, and muscle breakdown, which have produced rhabdomyolysis and acute kidney failure. As mentioned, a literature search produced 3 reports of sudden cardiac death attributed to α-PVP. In all 3 patients, autopsy revealed acute heart failure and pulmonary edema to be the cause of death in otherwise young healthy patients. Our patient was the first to demonstrate intracardiac thrombi. Important questions are raised. Does α-PVP affect the coagulation cascade? Is α-PVP intrinsically cardiotoxic? In animal studies, preadministration of antidopaminergic compounds has been shown to decrease the locomotor effects.7Kaizaki A. Tanaka S. Numazawa S. New recreational drug 1-phenyl-2-(1-pyrrolidinyl)-1-pentanone (alpha-PVP) activates central nervous system via dopaminergic neuron.J Toxicol Sci. 2014; 39: 1-6Crossref PubMed Scopus (50) Google Scholar Could these same compounds prevent or treat the cardiovascular effects as well? Further investigation is warranted as the availability and diversity of synthetic stimulants reaches epidemic proportions.

NATIVE VALVULAR regurgitation accounts for 35% to 45% of all valvular heart disease. 1 Iung B. Baron G. Butchart E.G. et al. A prospective survey of patients with valvular heart disease in Europe: The Euro Heart Survey on valvular heart disease. Eur Heart J. 2003; 24: 1231-1243 Crossref PubMed Scopus (2633) Google Scholar , 2 Andell P. Li X. Martinsson A. et al. Epidemiology of valvular heart disease in a Swedish nationwide hospital-based register study. Heart. 2017; 103: 1696-1703 Crossref PubMed Scopus (145) Google Scholar The effect on society is clear with more than 100,000 cardiac valve surgeries occurring annually in the United States. Cardiac anesthesiologists play a pivotal role in these procedures because the use of intraoperative transesophageal echocardiography (TEE) influences the evaluation and frequently the surgical plan. The American Society of Echocardiography (ASE) recently provided an overdue comprehensive update of its 2003 guidelines on the evaluation of native valvular regurgitation. Within this period, remarkable changes in the understanding of regurgitant lesions, diagnostic modalities, and treatment for these lesions have taken place. This narrative review focuses on the most important principles for cardiac anesthesiologists, considering environmental limitations, in a stepwise fashion for each of the regurgitant lesions. Emphasis is placed first on mechanisms of disease followed by the implications of these mechanisms on both old and new diagnostic modalities. Of note, most assessment recommendations are derived from transthoracic echocardiography (TTE) examinations and have been extrapolated to TEE views. Lastly, newer diagnostic modalities, although discussed, may not have specific quantification values defined. European guidelines may be referenced for these values. 3 Lancellotti P. Tribouilloy C. Hagendorff A. et al. Recommendations for the echocardiographic assessment of native valvular regurgitation: An executive summary from the European Association of Cardiovascular Imaging. Eur Heart J Cardiovasc Imaging. 2013; 14: 611-644 Crossref PubMed Scopus (1095) Google Scholar

Abstract Background: Although the use of an anesthesiology “airway” rotation to train the nonanesthesiologist is commonly employed, little data exist on the utility, clinical exposure, and outcomes of these programs. Methods: A prospectively collected observational dataset of airway procedures completed by trainees in a 4-week, anesthesiology-based, airway rotation at an academic, level-1 trauma center from July 2010 to September 2012 was reviewed. Prospectively defined data points were collected through an online data tool and included patient demographics, location, date, best laryngoscopic view, and attempt details. At the authors’ institution, an attending trauma anesthesiologist is present for all intubation attempts. The primary outcome was first-attempt success. Results: A total of 4,282 self-reported, airway procedures were identified. The median number of procedures performed was 50.4 ± 13.2 (range, 20 to 93; 25th quartile = 41; 75th quartile = 57). Multivariate logistic regression analysis modeling of first-attempt success rate identified two independent predictors of success: rotation week (odds ratio, 1.42; 95% CI, 1.32 to 1.61; P < 0.0001) and number of previous intubation attempts before rotation (odds ratio, 1.23; 95% CI, 1.03 to 1.46; P = 0.02. In addition, the percentage of cases with a self-reported laryngoscopic grade 1 view increased significantly from 61 to 74% ( P = 0.015) from week 1 to week 4 of the rotation. Conclusions: An anesthesiology-based program for airway training of nonanesthesiologists demonstrates improved self-reported, perceived first-attempt success over the course of training with improved ability to visualize glottic structures.

Background: Although the use of an anesthesiology "airway" rotation to train the nonanesthesiologist is commonly employed, little data exist on the utility, clinical exposure, and outcomes of these programs.Methods: A prospectively collected observational dataset of airway procedures completed by trainees in a 4-week, anesthesiology-based, airway rotation at an academic, level-1 trauma center from July 2010 to September 2012 was reviewed. Prospectively defined data points were collected through an online data tool and included patient demographics, location, date, best laryngoscopic view, and attempt details. At the authors' institution, an attending trauma anesthesiologist is present for all intubation attempts. The primary outcome was first-attempt success.Results: A total of 4,282 self-reported, airway procedures were identified. The median number of procedures performed was 50.4 +/- 13.2 (range, 20 to 93; 25th quartile = 41; 75th quartile = 57). Multivariate logistic regression analysis modeling of first-attempt success rate identified two independent predictors of success: rotation week (odds ratio, 1.42; 95% CI, 1.32 to 1.61; P < 0.0001) and number of previous intubation attempts before rotation (odds ratio, 1.23; 95% CI, 1.03 to 1.46; P = 0.02. In addition, the percentage of cases with a self-reported laryngoscopic grade 1 view increased significantly from 61 to 74% (P = 0.015) from week 1 to week 4 of the rotation.Conclusions: An anesthesiology-based program for airway training of nonanesthesiologists demonstrates improved self-reported, perceived first-attempt success over the course of training with improved ability to visualize glottic structures.