Predictors and neurological consequences of periprocedural cerebrovascular events following transcatheter aortic valve implantation with self-expanding valves

Ferenc Imre Suhai; Andrea Varga; Bálint Szilveszter; Milán Nagy-Vecsey; Astrid Apor; Anikó Ilona Nagy; Márton Kolossváry; Júlia Karády; Andrea Bartykowszki; Levente Molnár; Ádám L Jermendy; Alexisz Panajotu; Pál Maurovich-Horvat; Béla Merkely

doi:10.3389/fcvm.2022.951943

Predictors and neurological consequences of periprocedural cerebrovascular events following transcatheter aortic valve implantation with self-expanding valves

Front Cardiovasc Med. 2022 Oct 5:9:951943. doi: 10.3389/fcvm.2022.951943. eCollection 2022.

Authors

Ferenc Imre Suhai¹, Andrea Varga¹, Bálint Szilveszter¹, Milán Nagy-Vecsey¹, Astrid Apor¹, Anikó Ilona Nagy^{1

2}, Márton Kolossváry^{1

3}, Júlia Karády^{1

3}, Andrea Bartykowszki¹, Levente Molnár¹, Ádám L Jermendy¹, Alexisz Panajotu¹, Pál Maurovich-Horvat⁴, Béla Merkely¹

Affiliations

¹ Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Budapest, Hungary.
² Department of Medicine, Karolinska Institute, Stockholm, Sweden.
³ Cardiovascular Imaging Research Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States.
⁴ Medical Imaging Center, Semmelweis University, Budapest, Hungary.

Abstract

Aims: To evaluate the patient- and procedure-related predictors of transcatheter aortic-valve implantation (TAVI)-associated ischemic brain lesions and to assess the effect of silent cerebral ischemic lesions (SCIL) on neurocognitive function.

Methods and results: We investigated 113 consecutive patients with severe aortic stenosis who underwent brain magnetic resonance imaging (MRI) within a week following TAVI. To assess periprocedural cerebral ischemic lesions, diffusion-weighted MRI was utilized. We used multivariate linear regression to identify the independent predictors of TAVI-related ischemic lesion volume (ILV) and periprocedural stroke. Neurocognitive evaluation was performed before and following TAVI at 6-month and one-year follow-up. Following TAVI, a total of 944 new cerebral ischemic lesions were detected in 104 patients (92%). The median ILV was 257 μl (interquartile range [IQR]:97.1-718.8μl) with a median lesion number of 6/patient [IQR:2-10]. The majority of ischemic lesions were clinically silent (95%), while 5% of the lesions induced a stroke, which was confirmed by MRI. Predilatation (β = 1.13[95%CI:0.32-1.93], p = 0.01) and the number of valve positioning attempts during implantation (β = 0.28[95%CI:0.06-0.50], p = 0.02) increased the log-transformed total ILV. Predilatation (OR = 12.04[95%CI:1.46-99.07], p = 0.02) and alternative access routes (OR = 7.84[95%CI:1.01-61.07], p = 0.02) were associated with stroke after adjustments for comorbidities and periprocedural factors. The presence of SCILs were not associated with a change in neurocognitive function that remained stable during the one-year follow-up.

Conclusion: While periprocedural ischemic lesions are frequent, most of them are clinically silent and might not impact the patients' neurocognitive function. The number of valve positioning attempts, predilatation, and alternative access routes should be taken into consideration during TAVI to reduce the ILV and risk for stroke.

Keywords: cardiac CT angiography (CTA); cerebral embolism; magnetic resonance imaging; stroke; transcatheter aortic valve implantation.