Neurological Injury in Intermediate‐Risk Transcatheter Aortic Valve Implantation

Abstract

BackgroundThe application of transcatheter aortic valve implantation (TAVI) to intermediate‐risk patients is a controversial issue. Of concern, neurological injury in this group remains poorly defined. Among high‐risk and inoperable patients, subclinical injury is reported on average in 75% undergoing the procedure. Although this attendant risk may be acceptable in higher‐risk patients, it may not be so in those of lower risk.Methods and ResultsForty patients undergoing TAVI with the Edwards SAPIEN‐XT ™ prosthesis were prospectively studied. Patients were of intermediate surgical risk, with a mean±standard deviation Society of Thoracic Surgeons score of 5.1±2.5% and a EuroSCORE II of 4.8±2.4%; participant age was 82±7 years. Clinically apparent injury was assessed by serial National Institutes of Health Stroke Scale assessments, Montreal Cognitive Assessments (MoCA), and with the Confusion Assessment Method. These identified 1 (2.5%) minor stroke, 1 (2.5%) episode of postoperative delirium, and 2 patients (5%) with significant postoperative cognitive dysfunction. Subclinical neurological injury was assessed using brain magnetic resonance imaging, including diffusion‐weighted imaging (DWI) sequences preprocedure and at 3±1 days postprocedure. This identified 68 new DWI lesions present in 60% of participants, with a median±interquartile range of 1±3 lesions/patient and volumes of infarction of 24±19 μL/lesion and 89±218 μL/patient. DWI lesions were associated with a statistically significant reduction in early cognition (mean ΔMoCA −3.5±1.7) without effect on cognition, quality of life, or functional capacity at 6 months.ConclusionsObjectively measured subclinical neurological injuries remain a concern in intermediate‐risk patients undergoing TAVI and are likely to manifest with early neurocognitive changes.Clinical Trial Registration URL: http://www.anzctr.org.au. Australian & New Zealand Clinical Trials Registry: ACTRN12613000083796.

Postoperative Delirium in Individuals Undergoing Transcatheter Aortic Valve Replacement: A Systematic Review and Meta‐Analysis

“…The majority of participants included in our meta‐analysis were derived from 2 large prospective registries, with the lack of information regarding delirium diagnostic criteria and timing of the delirium screening . Interestingly, while these 2 large studies reported lower incidence of IHPOD after TAVR (e.g., 3.8% and 4.6%), small studies included in our analysis report higher incidence of IHPOD after TAVR . Several participant‐ and procedural‐related factors, including age at admission, comorbid condition, TAVR access, and hospital complication rate, could explain the differences in the incidence of IHPOD between these studies.…”

Cognitive Outcomes After Transcatheter Aortic Valve Implantation: A Metaanalysis

“…Seven studies assessed cognitive outcomes one month after TAVI (n = 287) . Overall cognitive performance significantly improved after TAVI (SMD = −0.33, 95% CI = −0.50 to −0.16; z = 3.83, P < .001) (Figure ).…”

“…Cognitive function 6 months after TAVI was assessed in 4 studies (n = 326) . Overall cognitive performance remained unchanged 6 months after TAVI (SMD = −0.06, 95% CI = −0.21–0.10; z = 0.73, p = .47) (Figure ).…”

“…In studies with multiple TAVI intervention groups, groups were combined for the overall analysis . For studies that did not report means and standard deviations of cognitive scores, the values were extracted from graphs or calculated (from medians, interquartile ranges, or confidence intervals (CIs)) using the Cochrane Handbook for Systematic Reviews of Interventions guidelines…”

Early cerebrovascular events after transcatheter aortic valve replacement: patient- and procedure-specific predictors

“…Clinical syndromes vary widely, from transient neurological deficits which completely resolve (TIA); to subtle, clinically-apparent stroke which may lie undetected; to minor or major stroke, or even death. Additionally, clinically-silent events have been detected at an alarming rate by magnetic resonance imaging (MRI) (7), with an incidence of 60% even among intermediate-risk patients (8). However, the impact of subclinical or silent CVEs over both the short-and long-term remains controversial (9).…”