The Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia; The Heart & Lung Institute, Metro North Hospital and Health Service, Brisbane, Australia; The University of Queensland, Brisbane, Australia.
The University of Queensland, Brisbane, Australia; Department of Medical Imaging, The Prince Charles Hospital, Brisbane, Australia.
Am Heart J. 2018 Mar;197:113-123. doi: 10.1016/j.ahj.2017.12.008. Epub 2017 Dec 8.
Transcatheter aortic valve implantation (TAVI) is associated with a high incidence of cerebrovascular injury. As these injuries are thought to be primarily embolic, neuroprotection strategies have focused on embolic protection devices. However, the topographical distribution of cerebral emboli and how this impacts on the effectiveness of these devices have not been thoroughly assessed. Here, we evaluated the anatomical characteristics of magnetic resonance imaging (MRI)-defined cerebral ischemic lesions occurring secondary to TAVI to enhance our understanding of the distribution of cardioembolic phenomena.
Forty patients undergoing transfemoral TAVI with an Edwards SAPIEN-XT valve under general anesthesia were enrolled prospectively in this observational study. Participants underwent brain MRI preprocedure, and 3 ± 1 days and 6 ± 1 months postprocedure.
Mean ± SD participant age was 82 ± 7 years. Patients had an intermediate to high surgical risk, with a mean Society of Thoracic Surgeons score of 6.3 ± 3.5 and EuroSCORE of 18.1 ± 10.6. Post-TAVI, there were no clinically apparent cerebrovascular events, but MRI assessments identified 83 new lesions across 19 of 31 (61%) participants, with a median ± interquartile range number and volume of 1 ± 2.8 lesions and 20 ± 190 μL per patient. By volume, 80% of the infarcts were cortical, 90% in the posterior circulation and 81% in the right hemisphere.
The distribution of lesions that we detected suggests that cortical gray matter, the posterior circulation, and the right hemisphere are all particularly vulnerable to perioperative cerebrovascular injury. This finding has implications for the use of intraoperative cerebral embolic protection devices, particularly those that leave the left subclavian and, therefore, left vertebral artery unprotected.
经导管主动脉瓣植入术（TAVI）与脑血管损伤的发生率较高有关。由于这些损伤被认为主要是栓塞性的，因此神经保护策略集中在栓塞保护装置上。然而，尚未彻底评估脑栓塞的地形分布以及这如何影响这些装置的有效性。在这里，我们评估了继发于 TAVI 的磁共振成像（MRI）定义的脑缺血性病变的解剖特征，以增强我们对心源性栓塞现象分布的理解。
前瞻性地纳入了 40 名接受全身麻醉下经股动脉 TAVI 治疗并植入 Edwards SAPIEN-XT 瓣膜的患者。所有患者在术前、术后 3 ± 1 天和 6 ± 1 个月进行了脑部 MRI 检查。
患者的平均年龄 ± 标准差为 82 ± 7 岁。患者的手术风险处于中高危水平，平均胸外科医师协会评分（STS）为 6.3 ± 3.5，欧洲心脏手术风险评分（EuroSCORE）为 18.1 ± 10.6。TAVI 后，无明显的脑血管事件，但 MRI 评估发现 31 名患者中的 19 名（61%）有 83 个新病变，中位数 ± 四分位距的病变数量和体积分别为 1 ± 2.8 个和 20 ± 190 μL/患者。就体积而言，80%的梗死灶位于皮质，90%位于后循环，81%位于右侧半球。
我们检测到的病变分布表明，皮质灰质、后循环和右侧半球都特别容易受到围手术期脑血管损伤的影响。这一发现对术中脑栓塞保护装置的使用具有重要意义，特别是那些留下左侧锁骨下动脉和因此左侧椎动脉未受保护的装置。
