Neurocognition and Brain Lesion Burden Before TAVR

Study Questions:

What is the full extent of cognitive function before transcatheter aortic valve replacement (TAVR), and the degree to which there is an association with preprocedural brain pathology, as measured by 3-T T2 fluid-attenuated inversion recovery (FLAIR) imaging?

Methods:

The investigators used data from the SENTINEL (Cerebral Protection in Transcatheter Aortic Valve Replacement) trial. The study population comprised subjects with severe symptomatic calcified native aortic valve stenosis who met the commercially approved indications for TAVR. Patients had cognitive assessments of attention, processing speed, executive function, and verbal and visual memory. Z-scores were based on normative means and standard deviations (SDs), combined into a primary composite z-score. Brain magnetic resonance images (MRIs) were obtained pre-TAVR on 3-T scanners with a T2 FLAIR sequence. Scores ≤-1.5 SD below the normative mean (7th percentile) were considered impairment. Paired t-tests compared within-subject scores, and chi-square goodness-of-fit compared the percentage of subjects below -1.5 SD. Correlation and regression analyses assessed the relationship between neurocognitive z-scores and T2 lesion volume.

Results:

Among 234 patients tested, the mean composite z-score was -0.65 SD below the normative mean. Domain scores ranged from -0.15 SD for attention to -1.32 SD for executive function. On the basis of the ≥1.5 SD normative reference, there were significantly greater percentages of impaired scores in the composite z-score (13.2%; p = 0.019), executive function (41.9%; p < 0.001), verbal memory (p < 0.001), and visual memory (p < 0.001). The regression model between FLAIR lesion volume and baseline cognition showed statistically significant negative correlations.

Conclusions:

The authors concluded that there was a significant proportion of aortic stenosis patients with impaired cognition before TAVR, with a relationship between baseline cognitive function and lesion burden likely attributable to longstanding cerebrovascular disease.

Perspective:

This study reports that a significant proportion of older TAVR patients with high surgical risk have impaired cognitive domains before intervention. In addition, there was a significant relationship between baseline cognitive function and pre-TAVR MRI brain lesion burden, which is likely attributable to underlying cerebrovascular disease. It is understandable that there was no further loss over time after TAVR, given the level of pre-TAVR cognitive dysfunction present, producing a floor effect. Additional studies are indicated to assess whether lower-risk patients with presumably less burden of cerebrovascular disease will be at a higher risk for post-TAVR cognitive dysfunction.

Clinical Topics: Cardiac Surgery, Geriatric Cardiology, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Valvular Heart Disease, Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and VHD, Interventions and Imaging, Interventions and Structural Heart Disease, Interventions and Vascular Medicine, Magnetic Resonance Imaging, Sleep Apnea

Keywords: Aortic Valve Stenosis, Cerebrovascular Disorders, Cognition, Cognition Disorders, Diagnostic Imaging, Executive Function, Geriatrics, Heart Valve Diseases, Magnetic Resonance Imaging, Magnetic Resonance Spectroscopy, Memory, Secondary Prevention, Transcatheter Aortic Valve Replacement, Vascular Diseases


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