Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA; Yale Cardiovascular Research Group, New Haven, Connecticut USA.
Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA; Yale Cardiovascular Research Group, New Haven, Connecticut USA.
J Am Coll Cardiol. 2024 Aug 20;84(8):712-722. doi: 10.1016/j.jacc.2024.05.055.
Acute brain infarction detected by diffusion-weighted magnetic resonance imaging (DW-MRI) is common after transcatheter aortic valve replacement (TAVR), but its clinical relevance is uncertain.
The authors investigated the relationship between DW-MRI total lesion number (TLN), individual lesion volume (ILV), and total lesion volume (TLV) and clinical stroke outcomes after TAVR.
Patient-level data were pooled from 4 prospective TAVR embolic protection studies, with consistent predischarge DW-MRI acquisition and core laboratory analysis. C-statistic was used to determine the best DW-MRI measure associated with clinical stroke.
A total of 495 of 603 patients undergoing TAVR completed the predischarge DW-MRI. At 30 days, the rate of clinical ischemic stroke was 6.9%. Acute ischemic brain injury was seen in 85% of patients with 5.5 ± 7.3 discrete lesions per patient, mean ILV of 78.2 ± 257.1 mm, and mean TLV of 555 ± 1,039 mm. The C-statistic was 0.84 for TLV, 0.81 for number of lesions, and 0.82 for maximum ILV in predicting ischemic stroke. On the basis of the TLV cutpoint as defined by receiver operating characteristic (ROC), patients with a TLV >500 mm (vs TLV ≤500 mm) had more ischemic stroke (18.2% vs 2.3%; P < 0.0001), more disabling strokes (8.8% vs 0.9%; P < 0.0001), and less complete stroke recovery (44% vs 62.5%; P = 0.001) at 30 days.
Our study confirms that the number, size, and total volume of acute brain infarction defined by DW-MRI are each associated with clinical ischemic strokes, disabling strokes, and worse stroke recovery in patients undergoing TAVR and may have value as surrogate outcomes in stroke prevention trials. (A Prospective, Randomized Evaluation of the TriGuard™ HDH Embolic Deflection Device During TAVI [DEFLECT III]; NCT02070731) (A Study to Evaluate the Neuro-embolic Consequences of TAVR [NeuroTAVR]; NCT02073864) (The REFLECT Trial: Cerebral Protection to Reduce Cerebral Embolic Lesions After Transcatheter Aortic Valve Implantation [REFLECT I]; NCT02536196) (The REFLECT Trial: Cerebral Protection to Reduce Cerebral Embolic Lesions After Transcatheter Aortic Valve Implantation [REFLECT II]; NCT02536196).
经扩散加权磁共振成像（DW-MRI）检测到的急性脑梗死在经导管主动脉瓣置换术（TAVR）后很常见，但其临床相关性尚不确定。
作者研究了 DW-MRI 总病变数（TLN）、单个病变体积（ILV）和总病变体积（TLV）与 TAVR 后临床卒中结局之间的关系。
从 4 项前瞻性 TAVR 栓塞保护研究中汇总了患者水平的数据，均进行了一致的出院前 DW-MRI 采集和核心实验室分析。C 统计量用于确定与临床卒中最相关的 DW-MRI 指标。
共有 603 例接受 TAVR 的患者中有 495 例完成了出院前 DW-MRI。30 天时，临床缺血性卒中发生率为 6.9%。85%的患者出现急性缺血性脑损伤，每个患者有 5.5±7.3 个离散病变，平均 ILV 为 78.2±257.1mm，平均 TLV 为 555±1039mm。TLV 的 C 统计量为 0.84，病变数量为 0.81，最大 ILV 为 0.82，均能预测缺血性卒中。基于受试者工作特征（ROC）曲线的 TLV 截断值，TLV＞500mm（与 TLV≤500mm 相比）的患者发生缺血性卒中（18.2%比 2.3%；P＜0.0001）、致残性卒中（8.8%比 0.9%；P＜0.0001）和卒中恢复较差（44%比 62.5%；P=0.001）的风险更高。
本研究证实，DW-MRI 定义的急性脑梗死的数量、大小和总体积均与 TAVR 患者的临床缺血性卒中和致残性卒中和卒中恢复不良相关，可能作为卒中预防试验中的替代结局指标。（一项前瞻性、随机评估 TriGuard™ HDH 栓塞偏转装置在 TAVI 中的应用的研究[DEFLECT III]；NCT02070731）（一项评估 TAVR 后神经栓塞后果的研究[NeuroTAVR]；NCT02073864）（REFLECT 试验：经导管主动脉瓣植入术后减少脑栓塞病变的脑保护[REFLECT I]；NCT02536196）（REFLECT 试验：经导管主动脉瓣植入术后减少脑栓塞病变的脑保护[REFLECT II]；NCT02536196）。
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