An 84-year-old female patient suffered from dyspnea due to severe aortic stenosis. Several comorbidities and her advanced age made her acceptable for transcatheter aortic valve implantation (TAVI). The TAVI procedure was performed via a femoral access and a 26-mm CoreValve prosthesis (Medtronic, Minneapolis, MN, USA) was implanted. The prosthesis was deployed at a high position because of short distance between the annulus base and coronary arteries. Aortic angiography indicated normal contrast flow into both coronary arteries. Six months later she was readmitted to our hospital because of acute coronary syndrome. Although selective intubation of coronary arteries could not be achieved because of high valve position, both coronary arteries seemed to be well contrasted. As a consequence, the second coronary angiography was undertaken because of recurring chest pains. The aortic root angiogram showed a decreased contrast flow into both coronary arteries. During the examination she deteriorated rapidly, developed cardiopulmonary arrest, and a percutaneous cardiopulmonary support and an intra-aortic balloon pump needed to be inserted. She was then transferred to the operating room for aortic valve replacement. This is the first case of delayed coronary ischemia after TAVI, necessitating the removal of an implanted CoreValve and its replacement with a new prosthetic valve.

A woman was admitted due to dyspnea. She had familial pulmonary arterial hypertension and typical echocardiographic findings including early diastolic bulging of the interventricular septum toward the left ventricular cavity. Her symptoms improved with medication. Five months later, she was hospitalized again due to severe dyspnea. Echocardiography demonstrated aortic valve vegetation and its regurgitation. Echocardiography also showed attenuation of early diastolic compression of the interventricular septum, however, the peak tricuspid regurgitant flow velocity did not improve. It is likely that development of left-sided heart failure attenuated abnormal interventricular septal motion due to pulmonary hypertension.

This study aimed to investigate the effect of a rehabilitation program combined with pain management targeting pain perception and activity avoidance on multifaceted outcomes in older patients with acute vertebral compression fractures (VCFs). We randomised 65 older adults with acute VCFs to either an intervention group (n = 32), involving usual rehabilitation combined with pain management that targeted pain perception and activity avoidance, or a control group (n = 33), involving only usual rehabilitation. The usual rehabilitation was initiated immediately after admission. All patients were treated conservatively. Pain management aimed to improve the patients’ daily behaviour by increasing their daily activities despite pain, rather than by focusing on eliminating the pain. Pain intensity and psychological statuses such as depression, pain catastrophising, and physical activity levels were assessed on admission. Two weeks postadmission and at discharge, physical performance measures were assessed along with the above-given measurements. A significant main effect of the group was observed for the intensity of lower back pain, favouring the intervention group (F = 5.135, p = 0.027 ). At discharge, it was significantly better in the intervention group than in the control group ( p = 0.011 ). A time-by-group interaction emerged for magnification of the pain catastrophising scale ( p = 0.012 ), physical activity levels ( p < 0.001 ), and six-minute walking distance ( p = 0.006 ), all favouring the intervention group. Rehabilitation programs combined with pain management targeting pain perception and activity avoidance could be an effective conservative treatment for older patients with acute VCFs.

Introduction: Early prediction of the outcome in patients with cardiopulmonary arrest (CPA) is important to select the optimal management. The pupil diameter is a simple neurological examination and it predicts the prognosis in patient with stroke. However, the clinical significance of pupil diameter in CPA has not been elucidated. Hypothesis: We hypothesized that pupil diameter would predict the prognosis of CPA patients. Methods: We retrospectively analyzed consecutive 45 patients with CPA and return of spontaneous circulation (ROSC) after cardiopulmonary resuscitation in our hospital. We analyzed age, sex, cause of CPA, time during CPA, pupil diameter at admission and death in hospital. Results: The mean of age was 67±20 years and male were 34 (76%). The median of CPA time was 33 min [25%, 75%; 22, 46] and pupil diameter was 4.8 mm [3.0, 6.0]. The 26 (58%) patients died in hospital after ROSC. There was no significant difference in age and sex between survival (n=19) and dead (n=26). The CPA time was significantly shorter in survival than that in dead (21 min [10, 39] vs 30 min [30, 52], p=0.005). Furthermore, pupil diameter was significantly smaller in survival compared with dead (3.0mm [2.5, 4.3] vs 5.0mm [4.4, 6.0]) (Figure). The receiver-operating characteristic (ROC) curve for survival after ROSC demonstrated that the area under curve was 0.73 and provided an optimal cut-off value at 4.0mm in pupil diameter with 75% sensitivity and 75% specificity. When CPA time was 28 minutes, the area under curve was 0.76, and sensitivity and specificity were 78% and 71%, respectively. Conclusion: As same as CPA time, pupil diameter is suggested to predict the outcome after ROSC in CPA patients.