Background Silent brain infarcts ( SBI ) are increasingly being recognized as an important complication of cardiac procedures as well as a potential surrogate marker for studies on brain injury. The extent of subclinical brain injury is poorly defined. Methods and Results We conducted a systematic review and meta‐analysis utilizing studies of SBI s and focal neurologic deficits following cardiac procedures. Our final analysis included 42 studies with 49 separate intervention groups for a total of 2632 patients. The prevalence of SBI s following transcatheter aortic valve implantation was 0.71 (95% CI 0.64‐0.77); following aortic valve replacement 0.44 (95% CI 0.31‐0.57); in a mixed cardiothoracic surgery group 0.39 (95% CI 0.28‐0.49); coronary artery bypass graft 0.25 (95% CI 0.15‐0.35); percutaneous coronary intervention 0.14 (95% CI 0.10‐0.19); and off‐pump coronary artery bypass 0.14 (0.00‐0.58). The risk ratio of focal neurologic deficits to SBI in aortic valve replacement was 0.22 (95% CI 0.15‐0.32); in off‐pump coronary artery bypass 0.21 (95% CI 0.02‐2.04); with mixed cardiothoracic surgery 0.15 (95% CI 0.07‐0.33); coronary artery bypass graft 0.10 (95% CI 0.05‐0.18); transcatheter aortic valve implantation 0.10 (95% CI 0.07‐0.14); and percutaneous coronary intervention 0.06 (95% CI 0.03‐0.14). The mean number of SBI s per patient was significantly higher in the transcatheter aortic valve implantation group (4.58 ± 2.09) compared with both the aortic valve replacement group (2.16 ± 1.62, P =0.03) and the percutaneous coronary intervention group (1.88 ± 1.02, P =0.03). Conclusions SBI s are a very common complication following cardiac procedures, particularly those involving the aortic valve. The high frequency of SBI s compared with strokes highlights the importance of recording this surrogate measure in cardiac interventional studies. We suggest that further work is required to standardize reporting in order to facilitate the use of SBI s as a routine outcome measure.
Background Silent brain infarcts (SBIs) are frequently identified after transcatheter aortic valve implantation (TAVI), when patients are screened with diffusion-weighted magnetic resonance imaging (DW-MRI). Outside the cardiac literature, SBIs have been correlated with progressive cognitive dysfunction; however, their prognostic utility after TAVI remains uncertain. This study’s main goals were to explore (i) the incidence of and potential risk factors for SBI after TAVI; and (ii) the effect of SBI on early post-procedural cognitive dysfunction (PCD). Methods and results A systematic literature review was performed to identify all publications reporting SBI incidence, as detected by DW-MRI after TAVI. Silent brain infarct incidence, baseline characteristics, and the incidence of early PCD were evaluated via meta-analysis and meta-regression models. We identified 39 relevant studies encapsulating 2408 patients. Out of 2171 patients who underwent post-procedural DW-MRI, 1601 were found to have at least one new SBI (pooled effect size 0.76, 95% CI: 0.72–0.81). The incidence of reported stroke with focal neurological deficits was 3%. Meta-regression noted that diabetes, chronic renal disease, 3-Tesla MRI, and pre-dilation were associated with increased SBI risk. The prevalence of early PCD increased during follow-up, from 16% at 10.0 ± 6.3 days to 26% at 6.1 ± 1.7 months and meta-regression suggested an association between the mean number of new SBI and incidence of PCD. The use of cerebral embolic protection devices (CEPDs) appeared to decrease the volume of SBI, but not their overall incidence. Conclusions Silent brain infarcts are common after TAVI; and diabetes, kidney disease, and pre-dilation increase overall SBI risk. While higher numbers of new SBIs appear to adversely affect early neurocognitive outcomes, long-term follow-up studies remain necessary as TAVI expands to low-risk patient populations. The use of CEPD did not result in a significant decrease in the occurrence of SBI.
Background: Minimally invasive surgical techniques pose alternatives to conventional surgery for the treatment of aortic stenosis (AS). We present a Bayesian network analysis comparing Valve Academic Research Consortium-2 clinical outcomes between transcatheter aortic valve implantation (TAVI), sutureless (SL-AVR) and conventional aortic valve replacement (CAVR). Methods: Electronic searches of databases were conducted and seven two-arm randomized-controlled trials and 25 propensity-score-matched studies comparing clinical outcomes of TAVI, SL-AVR and CAVR for treatment of AS were identified. Bayesian Markov chain Monte Carlo modelling was used to analyze clinical outcomes. Results: The analysis included 16,432 patients who underwent TAVI [7,056], SL-AVR [1,238] or CAVR [8,138]. Compared to CAVR, TAVI and SL-AVR were associated with reduced postoperative major bleeding of 59% (OR 0.41, 95% CI: 0.28-0.59) and 44% (OR 0.56, 95% CI: 0.30-0.99) respectively. TAVI had a 41% reduction in postoperative myocardial infarction (OR 0.59, 95% CI: 0.40-0.86) and SL-AVR had a 40% reduction in postoperative acute kidney injury (AKI) (OR 0.62, 95% CI: 0.42-0.86). Compared to TAVI, CAVR and SL-AVR had a reduction in moderate/severe paravalvular regurgitation of 89% (OR 0.11, 95% CI: 0.07-0.16) and 92% (OR 0.08, 95% CI: 0.03-0.17). CAVR had a 67% decreased postoperative permanent pacemaker (PPM) implantation compared to TAVI (OR 0.33, 95% CI: 0.24-0.45) and a 63% reduction compared to SL-AVR (OR 0.37, 95% CI: 0.22-0.61). There were no differences in 30-day mortality or postoperative stroke between the groups. Conclusions: In selected patients, minimally invasive surgical interventions including TAVI and SL-AVR for severe AS are viable alternatives to conventional surgery. However, TAVI is associated with increased paravalvular regurgitation, whereas TAVI and SL-AVR are associated with increased conduction disturbances compared to CAVR.
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