Neurological Injury in Intermediate-Risk Transcatheter Aortic Valve Implantation

J Am Heart Assoc. 2016 Nov 15;5(11):e004203. doi: 10.1161/JAHA.116.004203.

Abstract

Background: The 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 results: Forty 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.

Conclusions: Objectively 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.

Keywords: aortic stenosis; cerebrovascular disease/stroke; cognitive impairment; transcatheter aortic valve implantation.

Publication types

  • Observational Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Aged, 80 and over
  • Aortic Valve Stenosis / surgery*
  • Brain / diagnostic imaging
  • Cognitive Dysfunction / diagnostic imaging
  • Cognitive Dysfunction / epidemiology*
  • Delirium / diagnostic imaging
  • Delirium / epidemiology*
  • Diffusion Magnetic Resonance Imaging
  • Female
  • Humans
  • Magnetic Resonance Imaging
  • Male
  • Postoperative Complications / epidemiology*
  • Prospective Studies
  • Risk Assessment
  • Stroke / diagnostic imaging
  • Stroke / epidemiology*
  • Transcatheter Aortic Valve Replacement*

Associated data

  • ANZCTR/ACTRN12613000083796