Prognostic value of a comprehensive geriatric assessment for predicting one-year mortality in presumably frail patients with symptomatic aortic stenosis.

Introduction: Despite suffering a severe aortic stenosis, some patients are denied either surgical or transcatheter aortic valve implantation (TAVI) therapy because of a frail condition. We aimed to identify whether a comprehensive geriatric assessment (CGA) might be useful to predict the prognosis of presumably frail patients with severe aortic stenosis. Material and methods: Between March 2011 and July 2016, 818 patients were consecutively and prospectively enrolled. 161 had a CGA and were considered for analysis. Considering combined CGA and heart team recommendations, 102 TAVI procedures were performed (TAVI group) and 59 patients constituted the no-TAVI group. The primary endpoint was all-cause mortality at 1 year. Results: There was no difference between the TAVI and the no-TAVI groups considering morphometric data, cardiovascular risk factors or symptoms. The no-TAVI group had higher surgical risk (logistic EuroSCORE1 33.4 ±17.8 vs. 22.7 ±14.9; p < 0.001) and more moderate renal insufficiency (82% vs. 57%; p = 0.001). One-year mortality was 16% in the TAVI group and 46% in the no-TAVI group (p < 0.001). Multivariate analysis revealed that history of pulmonary edema, moderate renal failure, and not having a TAVI were associated with 1-year mortality. There was an interaction between the Five-Times-Sit-to-Stand-Test (FTSST) and the effect of TAVI on mortality (p = 0.049), as FTSST was the only predictor for 1-year mortality in the no-TAVI group (HR = 0.18, 95% CI: 0.04-0.76; p = 0.019). Conclusions: One-year mortality was higher in geriatric-assessed frail patients who did not undergo TAVI. FTSST, which assesses patients' mobility, was the only prognostic marker for 1-year mortality, on top of the usual medical parameters.

Is an ischemic origin in MINOCA patients predictable?

This study sought to identify parameters that could guide towards an ischemic origin in patients hospitalized for myocardial infarction (MI) with non-obstructive coronary arteries (MINOCA). MINOCA is challenging in clinical practice, as the pathophysiology is multifaceted. A total of 135 patients with MINOCA who underwent cardiovascular magnetic resonance imaging (CMR) in a single tertiary University Hospital, were retrospectively included. The study cohort was classified into 4 groups according to the CMR diagnosis (i.e., myocarditis, myocardial infarction, Takotsubo cardiomyopathy, normal or uncommon diagnosis). According to the CMR, 62% had myocarditis, 14.1% myocardial infarction, 4.4% of Takotsubo and 19.3% showed a normal CMR or uncommon diagnoses. In the multivariate analysis, three criteria were independently correlated with the underlying diagnosis of myocardial infarction: (1) the absence of inflammatory response (HR: 5.71 IC95% [1.79-18.28]; p = 0.002), (2) the presence of coronary atheroma in invasive coronary angiography (HR: 6.56 IC95% [2.27-18.92]; p = 0.001) and (3) a peak of troponin ratio elevated than normal levels of 150 (HR: 4.12 IC95% [1.45-11.65]; p = 0.01). The prevalence of myocardial infarction in MINOCA was 4.9% in the absence of these three criteria, 3.4% with one of the criteria present, 34.5% with two criteria present and 71.4% with all three criteria. The negative predictive value for MI was 96% in the presence of at least two criteria. Our study shows that the absence of inflammatory response, a high troponin and the presence of angiographic coronary atheroma are independently correlated with a myocardial infarction underlying cause of MINOCA.

Nonrevascularizable buttock claudication improved with Sildenafil: A case report.

RATIONALE: Sildenafil, a phosphodiesterase-5-inhibitor (PDE5i), could represent a new treatment in addition to the medical treatment and advice to walk in peripheral arterial disease (PAD). PATIENT CONCERNS AND DIAGNOSES: We report a case of a 62-year-old heavy smoker man who developed a buttock claudication and a severe walking limitation following an aorto-bi-femoral bypass in 1992. Since 2003, each year, he has been referred for investigation of bilateral buttock claudication on treadmill using transcutaneous oxygen pressure (tcpO2) measurement during exercise to argue for the vascular origin of the walking impairment. He had a severe bilateral buttock ischemia and the maximum walking distance (MWD) he reached was 258 m in 2011 despite the medical optimal treatment and walking rehabilitation. Ethical approval is not necessary for this case report according to the French legislation and written consent to publication was obtained from the patient. INTERVENTIONS: Sildenafil, 100 mg/d, was introduced in February 2015 and the MWD increased to 310 m only after 2 h after the first oral intake, then to 713 m after 3 weeks, and finally to 1313 m in January 2017. OUTCOMES: Recently, the patient is treated with Sildenafil 100 mg/d. He has no more pain during walking and his quality of life has improved. MAIN LESSONS TO LEARN: Sildenafil, a PDE5i, may represent a new therapeutic option in addition to the conventional optimal medical therapy in patients with arterial claudication. tcpO2 measurement during exercise is a promising technique for the diagnosis and monitoring of patients with PAD. A crossover, double-blind, prospective randomized monocenter study (ARTERIOFIL-NCT02832570) and a double-blind prospective randomized multicenter study (VALSTAR-NCT02930811) are ongoing to confirm our original observation.