An updated look at how cognitive impairment affects TAVR outcomes
Transcatheter aortic valve replacement (TAVR) patients who suffer from cognitive impairment face a higher risk of one-year mortality and developing post-operative delirium (POD), according to a new study published in the American Journal of Cardiology.[1]
“TAVR has been increasingly used in seniors, and evidence suggests better outcomes than surgical aortic valve replacement,” wrote first author Jackie Jia Lin Sim, a researcher with the National University of Singapore, and colleagues. “Although frailty has been shown to be associated with poorer outcomes after TAVR, the effect of pre-existing cognitive impairment on patient outcomes after TAVR remains unclear. Because nearly 70% of patients aged 60 years old and above suffer from cognitive impairment, a significant number of patients who underwent TAVR may be affected.”
Sim et al. performed a meta-analysis in search of answers, focusing on data from nearly 33,000 TAVR patients who participated in one of 14 clinical studies. The mean patient age was 83.2 years old, and 56.7% of patients were men. Approximately 15% of patients presented with cognitive impairment.
Overall, cognitive impairment was associated with an increased risk of mortality and developing POD. Mortality after six to 12 months was seen in 14.5% of patients with cognitive impairment and 7% of patients without cognitive impairment. POD, meanwhile, was seen in 29.5% of patients with cognitive impairment and 11.7% of patients without cognitive impairment.
“Previous studies have confirmed this link between cognitive impairment at baseline and POD,” the authors wrote, highlighting studies originally published in the American Journal of Cardiology in 2018 and JACC: Cardiovascular Interventions in 2020.[2, 3]
The team highlighted this “crucial” connection between cognitive impairment and POD, noting that POD can lead to even worse impairment, longer lengths of stay in the hospital and a lower overall quality of life. They noted that “postoperative strategies” are needed to reduce POD among this patient population, but more research is still required.
“Given that patients with cognitive impairment who underwent TAVR were shown to have significantly poorer outcomes than patients without cognitive impairment, it is worth considering the incorporation of cognitive impairment as one of the factors in the decision-making algorithm on the type of treatment such patients should receive,” the authors concluded.
Questions on the use of embolic protection during TAVR
Transcatheter embolic protection devices specifically designed for TAVR exist and are being used by some centers to reduce the amount of debris flowing up to the brain during procedures. However, trial data has not been as supportive of there use. One of the most highly anticipated lat-breaking presentations at the Transcatheter Cardovascular Therapeutics (TCT) 2022 meeting involved the results of the PROTECTED TAVR study. It assessed if the use of cerebral embolic protection (CEP) devices could reduce the risk of stroke during TAVR procedures.
Interventional cardiologist Samir Kapadia, MD, chair of the department of medicine at Cleveland Clinic, presented the results in front of a packed crowd Sept. 17. His team’s analysis was simultaneously published in full in the New England Journal of Medicine.[1]
Overall, the researchers found, Boston Scientific’s Sentinel Cerebral Protection System was not associated with a significant reduction in the number of periprocedural strokes within 72 hours of TAVR.
Despit the data, Kapadia still concluded that the Sentinel device should be considered for all TAVR patients going forward. Safety does not appear to be a major issue, Kapadia said during his presentation, so the use of these devices may often come down to cost considerations. The study did find that nearly all the embolic protection systems used in the study did capture debris during the procedure that flowed up into the carotid arteries.
Michael has more than 18 years of experience as a professional writer and editor. He has written at length about cardiology, radiology, artificial intelligence and other key healthcare topics.