Lansky Alexandra J, Brown David, Pena Constantino, Pietras Cody G, Parise Helen, Ng Vivian G, Meller Stephanie, Abrams Kevin J, Cleman Michael, Margolis Pauliina, Petrossian George, Brickman Adam M, Voros Szilard, Moses Jeffrey, Forrest John K
Division of Cardiology, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut; Department of Cardiology, Yale Cardiovascular Research Group, New Haven, Connecticut.
Department of Cardiology, The Heart Hospital, Baylor Plano, Plano, Texas.
Am J Cardiol. 2016 Nov 15;118(10):1519-1526. doi: 10.1016/j.amjcard.2016.08.013. Epub 2016 Aug 23.
Cerebral embolization during transcatheter aortic valve implantation (TAVI) can lead to a spectrum of clinically relevant manifestations, ranging from overt stroke to mild neurologic or cognitive deficits and subclinical cerebral infarcts. This study sought to determine the frequency of neurologic injury, cerebral ischemic lesions, and cognitive dysfunction in subjects undergoing contemporary commercial TAVI in the United States. Neuro-TAVR is the first prospective, multicenter study to use serial systematic neurologic and cognitive assessments and diffusion-weighted magnetic resonance imaging (at 4 ± 2 days after procedure) to investigate the incidence and severity of neurologic injury after contemporary unprotected TAVI in the United States. A total of 44 consecutive patients underwent TAVI at 5 US sites. Diffusion-weighted magnetic resonance imaging lesions were detected in 94%, with a mean of 10.4 ± 15.3 lesions per subject and a median total lesion volume of 295 mm (interquartile range 71.6 to 799.6 mm). New neurologic impairment (worsening in National Institutes of Health Stroke Scale score from baseline with new cerebral lesions) occurred in 22.6% (7 of 31) of subjects at discharge and 14.8% (4 of 27) at 30 days. In addition, cognitive decrements from baseline were identified by the Montreal Cognitive Assessment in 33% (12 of 36) of subjects at discharge and 41% (13 of 32) at 30 days. In conclusion, this contemporary cohort of US patients confirms that TAVI results in cerebral infarction in most patients and that 1 in 5 patients have measurable neurologic impairment and 1 in 3 patients have decrease in cognitive measures by Montreal Cognitive Assessment score after TAVI, reinforcing the need for methods to mitigate the risk of brain injury during TAVI.
经导管主动脉瓣植入术（TAVI）期间的脑栓塞可导致一系列临床相关表现，从明显的中风到轻度神经或认知缺陷以及亚临床脑梗死。本研究旨在确定在美国接受当代商用TAVI的受试者中神经损伤、脑缺血性病变和认知功能障碍的发生率。神经TAVR是第一项前瞻性、多中心研究，采用系列系统性神经和认知评估以及扩散加权磁共振成像（术后4±2天）来调查美国当代无保护TAVI术后神经损伤的发生率和严重程度。共有44例连续患者在美国5个地点接受了TAVI。94%的患者检测到扩散加权磁共振成像病变，每位受试者平均有10.4±15.3个病变，总病变体积中位数为295 mm（四分位间距71.6至799.6 mm）。出院时22.6%（31例中的7例）的受试者出现新的神经功能损害（美国国立卫生研究院卒中量表评分较基线恶化且有新的脑病变），30天时为14.8%（27例中的4例）。此外，出院时33%（36例中的12例）的受试者通过蒙特利尔认知评估发现认知较基线下降，30天时为41%（32例中的13例）。总之，这一当代美国患者队列证实，TAVI导致大多数患者发生脑梗死，五分之一的患者有可测量的神经功能损害，三分之一的患者TAVI后蒙特利尔认知评估评分显示认知下降，这进一步强调了需要采取方法降低TAVI期间脑损伤风险。
