Journal of the American Heart Association: Cardiovascular and Cerebrovascular Disease (Oct 2016)

Neurological Injury in Intermediate‐Risk Transcatheter Aortic Valve Implantation

  • Jonathon P. Fanning,
  • Allan J. Wesley,
  • Darren L. Walters,
  • Eamonn M. Eeles,
  • Adrian G. Barnett,
  • David G. Platts,
  • Andrew J. Clarke,
  • Andrew A. Wong,
  • Wendy E. Strugnell,
  • Cliona O'Sullivan,
  • Oystein Tronstad,
  • John F. Fraser

DOI
https://doi.org/10.1161/JAHA.116.004203
Journal volume & issue
Vol. 5, no. 11

Abstract

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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 RegistrationURL: http://www.anzctr.org.au. Australian & New Zealand Clinical Trials Registry: ACTRN12613000083796.

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