Managing the patient undergoing transcatheter aortic valve replacement with ongoing mitral regurgitation.

INTRODUCTION: Significant mitral regurgitation (MR) frequently coexists in patients with severe symptomatic aortic stenosis undergoing transcatheter aortic valve replacement (TAVR). These patients have worse clinical outcomes than those with non-significant MR, especially if MR persists after treatment of the aortic stenosis. The optimal treatment approach for this challenging high-risk population is not well defined. AREAS COVERED: This review aims to present the current literature on concomitant significant MR in the TAVR population, and to provide a comprehensive algorithmic approach for clinical decision-making in this challenging cohort of patients. EXPERT OPINION: Concomitant mitral and aortic valve disease is a complex clinical entity. An exhaustive and comprehensive assessment of patient's clinical characteristics and mitral valve anatomy and function is required in order to assess the surgical risk, predict the MR response after AVR and evaluate the feasibility of percutaneous MV treatment if necessary. Further developments in transcatheter techniques will expand the indications for double valve treatment in operable and inoperable patients with concomitant significant MR and aortic stenosis.

Prognostic significance of reticulated platelet levels in diabetic patients with stable coronary artery disease.

Levels of reticulated platelets (RP) increase during high platelet turnover conditions, and have been shown to correlate with diabetes mellitus (DM) status. Little is known regarding the prognostic significance of levels of RP among patients with stable coronary artery disease (SCAD). The study consisted of patients with SCAD and DM, who visited our cardiology outpatient clinic between June 2016 and February 2017. RP levels were measured at baseline as immature platelet fraction (IPF)%, using flow cytometry. Outcomes at 2 years consisted of bleeding events and major adverse cardiovascular events (MACE), which included death, myocardial infarction, cerebrovascular accident and urgent revascularization. The study included 104 patients (mean age - 71.2 ± 9.5 years, 76.9% were male, and 83.7% had hypertension). IPF was significantly higher at baseline among patients who had suffered from a MACE (4.57% vs. 2.53%, p < .001), and lower in patients who had suffered from bleeding events, compared with those who had not (1.57% vs. 3.00%, p = .004). There were higher rates of MACE at higher IPF quartiles (p < .001, AUC-0.770), and higher rates of bleeding at the lowest quartiles (p = .007, AUC-0.781). In SCAD patients with DM, levels of RP are associated with a higher risk of MACE, and inversely correlated with the risk of bleeding.

Evaluation of framingham and systematic coronary risk evaluation scores by coronary computed tomographic angiography in asymptomatic adults.

Recently, coronary computed tomographic angiography (CCTA) was introduced as a tool for the early detection of coronary atherosclerosis. However, a disagreement exists regarding the accuracy of CCTA for the prediction of future cardiovascular risk compared to conventional clinical risks scores (e.g., Framingham and Systematic Coronary Risk Evaluation [SCORE] scores). The aim of the present study was to compare these 2 methods in asymptomatic Israeli subjects. CCTA was performed in 190 asymptomatic patients with ≥1 atherogenic risk factor as the primary screening tool for the presence of cardiovascular disease. The calcium score (CS) was measured in these subjects as a part of CCTA. In addition, the Framingham and SCORE scores were calculated, and statistical analysis using regression models was performed. The study included 190 subjects (84% men). The mean age was 55 ± 9.7 years. A significant correlation with the CS and plaque severity detected by CCTA was found when comparing the risk factors calculated by the SCORE and Framingham scores. A SCORE calculation of >2 versus <2 was related to a greater incidence of a CS >100 (42.9% vs 21.9; odds ratio [OR] 2.68, p = 0.001). When comparing high-risk (>4) and low-risk (<4) SCORE scores, the risk of atherosclerosis per CCTA was 50% versus 27.1% respectively (OR 2.7, p = 0.001). A high-risk Framingham (>20) versus low-risk Framingham (<20) score was related to a greater incidence of CS >100 (53.3% vs 28.6%; OR 3.18, p = 0.001). A high-risk versus low-risk SCORE score was related to greater plaque severity (79.2% vs 59.4%, respectively; OR 2.6, p = 0.001). A high-risk versus low-risk Framingham score was also related to greater plaque severity (93.3% vs 59%, respectively; OR 3.18, p = 0.001). The variables best predicting the severity of artery stenosis were age, gender, diabetes, and hypertension. In conclusion, the results of the present study indicate that the results of the Framingham and SCORE scores compared to those obtained using CCTA are good predictors of coronary artery disease. The use of these clinical scores seems important in identifying patients at risk of coronary atherosclerosis and treating them properly before the development of symptoms and also to help prevent the use of unnecessary invasive procedures.