West German Heart Center Essen, Department of Cardiology, University Duisburg-Essen, Hufelandstrasse 55, 45122 Essen, Germany.
Circulation. 2010 Feb 23;121(7):870-8. doi: 10.1161/CIRCULATIONAHA.109.855866.
The risk of stroke after transfemoral aortic valve implantation (TAVI) due to dislodgement and subsequent embolization of debris from aortic arch atheroma or from the calcified valve itself ranges between 2% and 10%. The rate of clinically silent cerebral ischemia is unknown but may be even higher.
Thirty-two patients who underwent TAVI with the use of a balloon-expandable (n=22) or self-expandable (n=10) stent valve prosthesis were included in this descriptive study and compared with a historical control group of 21 patients undergoing open surgical aortic valve replacement. Periprocedural apparent and silent cerebral ischemia was assessed by neurological testing and serial cerebral diffusion-weighted magnetic resonance imaging at baseline, at 3.4 (2.5 to 4.4) days after the procedure, and at 3 months. TAVI was successful in all patients. After the procedure, new foci of restricted diffusion on cerebral diffusion-weighted magnetic resonance imaging were found in 27 of 32 TAVI patients (84%) and were more frequent than after open surgery (10 of 21 patients [48%]; P=0.011). These lesions were usually multiple (1 to 19 per patient) and dispersed in both hemispheres in a pattern suggesting cerebral embolization. Volumes of these lesions were significantly smaller after TAVI than after surgery (77 [59 to 94] versus 224 [111 to 338] mm(3); P<0.001). There were neither measurable impairments of neurocognitive function nor apparent neurological events during the in-hospital period among TAVI patients, but there was 1 stroke (5%) in the surgical patient group. On 3-month follow-up diffusion-weighted magnetic resonance imaging, there were no new foci of restricted diffusion, and there was no residual signal change associated with the majority (80%) of the foci detected in the periprocedural period.
Clinically silent new foci of restricted diffusion on cerebral magnetic resonance imaging were detected in almost all patients (84%) undergoing TAVI. Although typically multiple, these foci were not associated with apparent neurological events or measurable deterioration of neurocognitive function during 3-month follow-up. Further work needs to be directed to determine the clinical significance of these findings in a larger patient population.
经股动脉主动脉瓣置换术（TAVI）后，由于主动脉弓粥样斑块或钙化瓣本身的碎片脱落和随后栓塞，中风的风险为 2%至 10%。临床无症状性脑缺血的发生率尚不清楚，但可能更高。
在这项描述性研究中，我们纳入了 32 例接受 TAVI 治疗的患者，其中 22 例使用球囊扩张型（n=22），10 例使用自扩张型（n=10）支架瓣膜假体，并与 21 例接受开放式主动脉瓣置换术的历史对照组进行比较。在基线、术后 3.4 天（2.5 至 4.4 天）和术后 3 个月，通过神经学检查和连续脑部弥散加权磁共振成像评估围手术期显型和隐匿性脑缺血。所有患者的 TAVI 均成功。术后，32 例 TAVI 患者中有 27 例（84%）发现新的弥散受限病灶，比开放式手术（21 例患者中有 10 例[48%]；P=0.011）更常见。这些病灶通常多发（每位患者 1 至 19 个病灶），呈弥漫性半球分布，提示为脑栓塞。TAVI 后这些病灶的体积明显小于手术组（77[59 至 94]与 224[111 至 338]mm3；P<0.001）。TAVI 患者在住院期间既没有可测量的神经认知功能损害，也没有明显的神经事件，但手术组有 1 例中风（5%）。在 3 个月的随访中，弥散加权磁共振成像上未发现新的弥散受限病灶，与围手术期检测到的大部分（80%）病灶相关的信号改变也没有残留。
在接受 TAVI 治疗的几乎所有患者（84%）中，脑部磁共振成像上检测到了隐匿性的新发弥散受限病灶。尽管这些病灶通常是多发的，但在 3 个月的随访中，它们与明显的神经事件或可测量的神经认知功能恶化无关。需要进一步的研究来确定这些发现在更大的患者人群中的临床意义。
