Dynamics of cerebral oxygenation during rapid ventricular pacing and its impact on outcome in transfemoral transcatheter aortic valve implantation

Abstract

Background: Cerebral O 2 saturation (ScO 2) reflects cerebral perfusion and can be measured noninvasively by near-infrared spectroscopy (NIRS). Objectives: In this pilot study, we describe the dynamics of ScO 2 during TAVI in nonventilated patients and its impact on procedural outcome. Methods and Results: We measured ScO 2 of both frontal lobes continuously by NIRS in 50 consecutive analgo-sedated patients undergoing transfemoral TAVI (female 58%, mean age 80.8 years). Compared to baseline ScO 2 dropped significantly during RVP (59.3% vs. 53.9%, p < .01). Five minutes after RVP ScO 2 values normalized (post RVP 62.6% vs. 53.9% during RVP, p < .01; pre 61.6% vs. post RVP 62.6%, p = .53). Patients with an intraprocedural pathological ScO 2 decline of >20% (n = 13) had higher EuroSCORE II (3.42% vs. 5.7%, p = .020) and experienced more often delirium (24% vs. 62%, p = .015) and stroke (0% vs. 23%, p < .01) after TAVI. Multivariable logistic regression revealed higher age and large ScO 2 drops as independent risk factors for delirium. Conclusions: During RVP ScO 2 significantly declined compared to baseline. A ScO 2 decline of >20% is associated with a higher incidence of delirium and stroke and a valid cutoff value to screen for these complications. NIRS measurement during TAVI procedure may be an easy to implement diagnostic tool to detect patients at high risks for cerebrovascular complications and delirium.

The Technological Basis of a Balloon-Expandable TAVR System: Non-occlusive Deployment, Anchorage in the Absence of Calcification and Polymer Leaflets

“…Every episode of RVP increases the incidence of new atrial fibrillation, acute kidney injury, in-hospital mortality and 1-year mortality ( 21 ). In a 2021 study, the significant decrease of cerebral oxygenation observed during RVP was a predictor for the occurrence of neurological complications such as TIA/stroke and post-intervention delirium ( 115 ). The Chinese consensus on TAVR recognizes this danger by stating that “the total pacing time should be <15 s to avoid serious complications caused by prolonged hypoperfusion” ( 53 ).…”

Cerebral Tissue Oxygen Saturation Is Enhanced in Patients following Transcatheter Aortic Valve Implantation: A Retrospective Study

“…Comparable values of rSO 2 were observed pre- and post-operatively, but intraoperative desaturation was more substantial during the implantation of balloon-expandable devices, which is due to the implantation technique. More substantial desaturations during RVP were observed in patients with a higher EuroScore, who also showed an overall reduction in rSO 2 in our cohort [ 26 ]. Preoperative rSO 2 was lower in patients with a higher EuroScore who underwent on-pump cardiac surgery, and these patients were found to have increased postoperative mortality [ 18 , 41 ].…”

“…However, although significant, the actual numerical rise in rSO 2 was small in our cohort, and it must therefore be considered that confounding factors contributed to these slightly elevated rSO 2 values. To date, evidence on the course of cerebral NIRS following TAVI has focused mainly on the episode of RVP [ 25 , 26 , 27 ]. Consistent to the functionally circulatory arrest that is achieved during RVP, rSO 2 was seen to fall significantly.…”

“…Consistent to the functionally circulatory arrest that is achieved during RVP, rSO 2 was seen to fall significantly. Interestingly, a decrease of more than 20% resulted in a higher incidence of POD, and these patients showed also lower rSO 2 baseline values [ 26 ]. Desaturation after RVP was also followed by transient hyperemia leading to elevated rSO 2 .…”

Thirty-day incidence of stroke after transfemoral transcatheter aortic valve implantation: meta-analysis and mixt-treatment comparison of self-expandable versus balloon-expandable valve prostheses

“…Implantation of BEV requires rapid ventricular pacing for stabilization of the aortic root and accurate positioning of the prosthesis. Rapid ventricular pacing causes a state of low to no cardiac output resulting in cerebral hypoperfusion and may be associated with increased stroke risk [ 37 , 38 ]. Balloon post-dilatation is routinely applied with SEV and BEV to reduce paravalvular leak and has been described as predictor for acute cerebrovascular events [ 39 ].…”