Lazar Ronald M, Myers Terina, Gropen Toby I, Leesar Massoud A, Davies James, Gerstenecker Adam, Norling Amani, Pavol Marykay A, Marshall Randolph S, Kodali Susheel
Department of Neurology, University of Alabama at Birmingham, 1720 7th Avenue South, SC650K, Birmingham, AL 35294, USA.
Department of Neurology, Columbia University Irving Medical Center, 710 W168th Street, NewYork, NY 10032, USA.
Eur Heart J Open. 2023 Dec 7;4(1):oead124. doi: 10.1093/ehjopen/oead124. eCollection 2024 Jan.
Aortic valve stenosis (AS) results in higher systolic pressure to overcome resistance from the stenotic valve, leading to heart failure and decline in cardiac output. There has been no assessment of cerebral blood flow (CBF) association with neurocognition in AS or the effects of valve replacement. The goal was to determine if AS is associated with altered cerebral haemodynamics and impaired neurocognition, and whether transcatheter aortic valve replacement (TAVR) improves haemodynamics and cognition.
In 42 patients with planned TAVR, transcranial Doppler (TCD) assessed bilateral middle cerebral artery (MCA) mean flow velocities (MFVs); abnormality was <34.45 cm/s. The neurocognitive battery assessed memory, language, attention, visual-spatial skills, and executive function, yielding a composite -score. Impairment was <1.5 SDs below the normative mean. The mean age was 78 years, 59% Male, and the mean valve gradient was 46.87 mm/Hg. Mean follow-up was 36 days post-TAVR (range 27-55). Pre-TAVR, the mean MFV was 42.36 cm/s (SD = 10.17), and the mean cognitive -score was -0.22 SDs (range -1.99 to 1.08) below the normative mean. Among the 34 patients who returned after TAVR, the MFV was 41.59 cm/s (SD = 10.42), not different from baseline ( = 0.66, 2.28-3.67). Post-TAVR, average Z-scores were 0.17 SDs above the normative mean, not meeting the pre-specified threshold for a clinically significant 0.5 SD change.
Among patients with severe AS, there was little impairment of MFV on TCD and no correlation with cognition. Transcatheter aortic valve replacement did not affect MFV or cognition. Assumptions about diminished CBF and improvement after TAVR were not supported.
主动脉瓣狭窄（AS）导致收缩压升高以克服狭窄瓣膜的阻力，从而导致心力衰竭和心输出量下降。目前尚无关于AS患者脑血流量（CBF）与神经认知之间的关联或瓣膜置换效果的评估。目标是确定AS是否与脑血流动力学改变和神经认知受损相关，以及经导管主动脉瓣置换术（TAVR）是否能改善血流动力学和认知功能。
在42例计划接受TAVR的患者中，经颅多普勒（TCD）评估双侧大脑中动脉（MCA）平均流速（MFV）；异常标准为<34.45 cm/s。神经认知测试评估记忆、语言、注意力、视觉空间技能和执行功能，得出一个综合评分。损害标准为低于正常均值1.5个标准差。平均年龄为78岁，男性占59%，平均瓣膜压差为46.87 mm/Hg。TAVR术后平均随访36天（范围27 - 55天）。TAVR术前，平均MFV为42.36 cm/s（标准差 = 10.17），平均认知评分为低于正常均值0.22个标准差（范围 -1.99至1.08）。在TAVR术后返回的34例患者中，MFV为41.59 cm/s（标准差 = 10.42），与基线无差异（P = 0.66，95%置信区间2.28 - 3.67）。TAVR术后，平均Z评分为高于正常均值0.17个标准差，未达到预先设定的具有临床意义的0.5个标准差变化阈值。
在重度AS患者中，TCD检测到的MFV几乎没有损害，且与认知无相关性。经导管主动脉瓣置换术未影响MFV或认知。关于TAVR后CBF减少及改善的假设未得到支持。
