Diffusion-weighted MRI determined cerebral embolic infarction following transcatheter aortic valve implantation: assessment of predictive risk factors and the relationship to subsequent health status

Abstract

Background 'Silent' cerebral infarction and stroke are complications of transcatheter aortic valve implantation (TAVI). Objective To assess the occurrence of cerebral infarction, identify predictive risk factors and examine the impact on patient health-related quality of life (HRQoL). Methods Cerebral diffusion weighted MRI of 31 patients with aortic stenosis undergoing CoreValve TAVI was carried out. HRQoL was assessed at baseline and at 30 days by SF-12v2 and EQ5D questionnaires. Results New cerebral infarcts occurred in 24/31 patients (77%) and stroke in 2 (6%). Stroke was associated with a greater number and volume of cerebral infarcts. Age (r¼0.37, p¼0.042), severity of atheroma (arch and descending aorta; r¼0.91, p<0.001, r¼0.69, p¼0.001, respectively) and catheterisation time (r¼0.45, p¼0.02) were predictors of the number of new cerebral infarcts. HRQoL improved overall: SF-12v2 physical component summary increased significantly (32.466.2 vs 36.567.2; p¼0.03) with no significant change in mental component summary (43.5611.7 vs 43.1614.3; p¼0.85). The EQ5D score and Visual Analogue Scale showed no significant change (0.5660.26 vs 0.5960.31; p¼0.70, and 54.2619 vs 58.2624; p¼0.43). Conclusion Multiple small cerebral infarcts occurred in 77% of patients with TAVI. The majority of infarcts were 'silent' with clinical stroke being associated with a both higher infarct number and volume. Increased age and the severity of aortic arch atheroma were independent risk factors for the development of new cerebral infarcts. Overall HRQoL improved and there was no association between the number of new cerebral infarcts and altered health status.

Silent ischemic brain lesions after transcatheter aortic valve replacement: lesion distribution and predictors

“…A comparable observation was reported by two other reports [5,7,18], with the largest portion of DWI lesions located on the left side of the brain. Two different hypotheses might explain this finding: (1) three major arteries, originating from the aortic arch, are at risk of receiving embolic particles from the calcified aortic valve and ascending aorta: the brachiocephalic, the left common carotid and the left subclavian arteries.…”

“…Future refinements to cerebral protection devices may offer full coverage of all three branch arteries of the aortic arch and hence better cerebral protection. With regard to potential risk factors for the development of new cerebral infarcts during TAVR, Fairbairn et al [7] reported old age and atherosclerotic burden of the aorta as independent predictors of the number of new cerebral ischemic lesions after these procedures. Astarci et al also found an association between age and the number of post-TAVR cerebral DWI lesions.…”

“…Furthermore, the average 30-day mortality in TAVR patients with post-procedural stroke was more than 3.5-fold higher than in non-stroke patients (25.5 vs. 6.9) [3]. In addition to the clinically apparent ischemic brain lesions, several cerebral magnetic resonance imaging studies have shown a very high (58-91 %) incidence of new ischemic lesions after TAVR, regardless of the transcatheter valve type and approach (Table 1) [4][5][6][7][8][9]. These small, usually asymptomatic, DWI lesions are most probably caused by micro-embolic particles arising during the valve implantation procedure.…”

Almanac 2013: novel non-coronary cardiac interventions

“…KliniËki MU je bio povezan s veÊim brojem i volumenom infarkta. 58 Studija SIMPLIFy TAVI istraaeivala je da li izbjegavanje balonske valvuloplastike za predilataciju nativne aortne valvule smanjuje rizik od MU tijekom TAVI. OËekuje se da se u prospektivnom registru CoreValve Advance II definiraju naËini za smanjenje potrebe za ugradnjom trajnog elektrostimulatora srca.…”

“…Clinical stroke was associated with higher infarct number and volume. 58 The SIMPLIFy TAVI study (Transcatheter Aortic Valve Implantation Without Predilation) is investigating whether the avoidance of balloon valvuloplasty for predilation of the native aortic valve reduces the stroke risk during TAVI. The CoreValve Advance II prospective registry is expected to define ways to reduce the need for permanent pacemaker implantation.…”