Cognitive Trajectory After Transcatheter Aortic Valve Implantation

Abstract

Background-Transcatheter aortic valve implantation (TAVI) is known to be associated with silent cerebral injury, which could contribute to cognitive impairment. Considering its increasing use, thorough longitudinal investigation of cognitive trajectory after TAVI is pivotal. Methods and Results-Repeatable battery for the assessment of neuropsychological status was performed before (E1), 3 days (E2), 3 months (E3), 1 (E4) year, and 2 years (E5) after TAVI. Baseline characteristics, procedural data, imaging parameters of brain injury (diffusion-weighted MRI), and the use of conceivable neuroprotective approaches were investigated for their effect on cognitive function. Cognitive performance was investigated in 111 patients (mean log EuroSCORE, 30±13%). Global cognitive function (repeatable battery for the assessment of neuropsychological status total score) increased transiently at E2 (P=0.02) and was comparable with baseline levels at E3, E4, and E5. Six patients (5.4%) demonstrated early cognitive decline. Persistence and late onset were seen infrequently (n=3, 2.7% and n=4, 3.6%, respectively). Hence, early cognitive decline was ruled out in 105 patients (94.6%), and a majority of patients (91%) demonstrated sustained cognitive performance throughout all investigated time points. Interestingly, only patient age (P=0.012), but not prior cerebrovascular events, cognitive status, direct TAVI, cerebral embolism in diffusion-weighted MRI, or the use of a cerebral embolic protection device was found to be independently associated with cognitive decline, linking higher age to cognitive impairment along the first 2 years after TAVI. Conclusions-Long-term cognitive performance was preserved in the great majority (91%) of patients throughout the first 2 years after TAVI, despite the high intrinsic risk for cognitive deterioration. Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT00883285.(Circ Cardiovasc Interv. 2013;6:615-624.)Key Words: cognition ◼ dementia ◼ injury ◼ intracranial embolism ◼ mild cognitive impairment ◼ stroke ◼ TAVR

Percutaneous aortic valve replacement has come to stay

“…Cerebral embolization, demonstrated by new ischemic defects detected by magnetic resonance imaging is highly frequent but it has limited clinical manifestation [25]. This study has also shown that the size of the ischemic defects, when they occur, are bigger in the surgical group in comparison with TAVR patients [26].…”

Embolic Protection Devices in Transcatheter Aortic Valve Replacement

“…Currently, there are a wide variety of neurocognitive tests, commonly termed the Neurocognitive Assessment Battery. 35 Some of the EPD trials have used these proposed batteries of neurocognitive tests, which have been used in previous clinical trials and have been piloted in the PARTNER II study. Similar studies in older populations have placed neurocognitive function testing as a primary outcome, pointing out that in this population the quality of life is not less important than life itself.…”

Stroke After Aortic Valve Replacement

“…Both SAVR and TAVR literature reported cognitive decline after the operation, but the clinical implication of these deficits is not well established. [7][8][9] This uncertainty is also true for silent neurological events (ie, events recorded by imaging modalities with no apparent clinical symptoms). Messé et al report a 54% incidence of silent brain infarcts that were demonstrated by diffusion-weighted imaging after the procedure in patients with no clinical neurological event.…”