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BACKGROUND Many patients experiencing acute coronary syndrome (ACS) present in cardiac arrest. Mechanical chest compressions are a common tool in cardiopulmonary resuscitation (CPR) and have their benefits as well as disadvantages and reported complications. In recent years, veno-arterial extracorporeal oxygenation membrane (VA-ECMO) has proven to be a promising tool in these circumstances and is now considered part of the treatment algorithm in emergent and refractory cases. The combination of mechanical compressions and the ECMO lead to "new" complicated situations in the patients. We discuss such a patient, who required emergent surgery due to complications from his resuscitation, while under ECMO. CASE REPORT A 56-year-old man, with medical history of cardiovascular risk factors, presented to our facility due to ST segment elevation myocardial infarction. During his catheterization, he went into cardiac arrest and needed cardiopulmonary resuscitation (CPR) using a LUCAS3™ device. Because no rhythm was restored, he was promptly placed on VA-ECMO support with immediate, albeit transient, stabilization. After transportation to our Intensive Care Unit (ICU), he quickly deteriorated again hemodynamically and after imaging workup it was discovered he had a major laceration to his liver and was rushed emergently to the operating room where he underwent partial hepatectomy, while on full anticoagulation due to the ECMO support. CONCLUSIONS Complications from mechanical CPR are common, including liver laceration. Patients who are placed on ECMO following such measures should be carefully evaluated for such complications as they might affect the treatment and prognosis.

BACKGROUND Atrial fibrillation is a common arrhythmia worldwide. The number of patients undergoing ablation as treatment is increasing, as is the incidence of complications from ablation. One such complication is atrio-esophageal fistula, which is rare but life threatening. We discuss 2 cases of patients that presented with a fistula several weeks following atrial fibrillation ablation. CASE REPORT A 67-year-old man and 64-year-old woman both had cardiovascular morbidity and chronic kidney disease, diabetes, and other chronic illnesses. Both patients presented approximately 6 weeks after radiofrequency atrial fibrillation ablation and were admitted with varying symptoms, including fever and neurological deficits mimicking a cerebrovascular accident or massive bleeding. Both patients deteriorated very rapidly in the department, especially after certain interventions, such as endoscopy, and exhibited deteriorating neurological signs, including loss of consciousness and basic brain stem reflexes, and head computed tomography (CT) showed widespread infarcts and hemorrhages. Owing to their history, a chest CT was performed at the same time, revealing an atrio-esophageal fistula, which was determined to be the cause of their illness and led to their eventual deaths. CONCLUSIONS A rare complication of atrial fibrillation ablation procedure is atrio-esophageal fistula, which if left untreated, is almost uniformly fatal, and even survivors are usually left with significant sequelae. It is important to recognize the rapid deterioration and possible signs and symptoms, such as gastrointestinal bleeding, fever, or even neurological abnormalities, and make the connection to the ablation procedure in terms of timeline for rapid diagnosis and prompt treatment.

Background: The DES-obstructive sleep apnea (DES-OSA) score uses morphological characteristics to predict the presence and severity of obstructive sleep apnea syndrome (OSAS)., Objectives: To validate DES-OSA scores on the Israeli population. To identify patients requiring treatment for OSAS. To evaluate whether additional parameters could improve the diagnostic value of DES-OSA scores., Methods: We performed a prospective cohort study on patients attending a sleep clinic. Polysomnography results were examined independently by two physicians. DES-OSA scores were calculated. STOP and Epworth questionnaires were administered, and data on cardiovascular risk was extracted., Results: We recruited 106 patients, median age 64 years, 58% male. DES-OSA scores were positively correlated with apnea-hypopnea index (AHI) (P < 0.001) and were significantly different between the OSAS severity groups. Interobserver agreement for calculating DES-OSA was very high between the two physicians (intraclass correlation coefficient 0.86). DES-OSA scores ≤ 5 were associated with high sensitivity and low specificity (0.90 and 0.27, respectively) for moderate to severe OSAS. In univariate analysis, only age was significantly correlated with the presence of OSAS (OR 1.26, P = 0.01). Age older than 66 years as a single point in the DES-OSA score slightly improved the sensitivity of the test., Conclusions: DES-OSA is a valid score based solely on physical examination, which may be useful for excluding OSAS requiring therapy. DES-OSA score ≤ 5 effectively ruled out moderate to severe OSAS. Age older than 66 years as an extra point improved the sensitivity of the test.