Department of Neurology, University of Alabama at Birmingham, Birmingham, Alabama.
Department of Neurology, Columbia University Medical Center, New York, New York.
JACC Cardiovasc Interv. 2018 Feb 26;11(4):384-392. doi: 10.1016/j.jcin.2017.10.041. Epub 2018 Feb 1.
The authors sought to determine baseline neurocognition before transcatheter aortic valve replacement (TAVR) and its correlations with pre-TAVR brain imaging.
TAVR studies have not shown a correlation between diffusion-weighted image changes and neurocognition. The authors wanted to determine the extent to which there was already impairment at baseline that correlated with cerebrovascular disease.
SENTINEL (Cerebral Protection in Transcatheter Aortic Valve Replacement) trial patients had cognitive assessments of attention, processing speed, executive function, and verbal and visual memory. Z-scores were based on normative means and SDs, combined into a primary composite z-score. Brain magnetic resonance images were obtained pre-TAVR on 3-T scanners with a T2 fluid-attenuated inversion recovery (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.
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.
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. These findings underscore the importance of pre-interventional testing and magnetic resonance imaging in any research investigating post-surgical cognitive outcomes in patients with cardiovascular disease.
作者旨在确定经导管主动脉瓣置换术（TAVR）前的神经认知基线，并研究其与 TAVR 前脑影像学的相关性。
TAVR 研究并未显示弥散加权图像变化与神经认知之间存在相关性。作者希望确定基线时已经存在与脑血管疾病相关的认知障碍的程度。
SENTINEL（经导管主动脉瓣置换术的脑保护）试验患者接受了注意力、处理速度、执行功能以及言语和视觉记忆的认知评估。Z 分数基于标准平均值和标准差，合并为主要复合 Z 分数。在 3T 扫描仪上使用 T2 液体衰减反转恢复（FLAIR）序列获得 TAVR 前脑磁共振图像。分数低于标准平均值（第 7 个百分位数）的-1.5 个标准差被认为是损伤。配对 t 检验比较了个体内的分数，卡方拟合优度检验比较了低于-1.5 个标准差的个体百分比。相关性和回归分析评估了神经认知 Z 分数与 T2 病变体积之间的关系。
在 234 名接受测试的患者中，平均复合 Z 分数低于标准平均值的-0.65 个标准差。各域分数范围从注意力的-0.15 个标准差到执行功能的-1.32 个标准差。根据≥1.5 个标准差的标准参考，复合 Z 分数（13.2%；p=0.019）、执行功能（41.9%；p<0.001）、言语记忆（p<0.001）和视觉记忆（p<0.001）的损伤分数百分比显著更高。FLAIR 病变体积与基线认知之间的回归模型显示出统计学上显著的负相关。
在 TAVR 前，有相当一部分主动脉瓣狭窄患者存在认知障碍，基线认知功能与病变负荷之间的关系可能归因于长期的脑血管疾病。这些发现强调了在任何研究心血管疾病患者手术后认知结果时，术前测试和磁共振成像的重要性。
