Skip to main content
Top
Gepubliceerd in:

Open Access 19-10-2023 | Commentary

Cognitive function after transcatheter aortic valve implantation: the forgotten child

Auteurs: Hugo M. Aarts, Michiel Voskuil

Gepubliceerd in: Netherlands Heart Journal | Uitgave 12/2023

share
DELEN

Deel dit onderdeel of sectie (kopieer de link)

  • Optie A:
    Klik op de rechtermuisknop op de link en selecteer de optie “linkadres kopiëren”
  • Optie B:
    Deel de link per e-mail
insite
ZOEKEN
Transcatheter aortic valve implantation (TAVI) has become routine treatment in patients with aortic valve stenosis and an increased surgical risk. Although the risk of periprocedural complications has decreased dramatically over the last decade, ischaemic stroke still remains a feared and detrimental complication in patients undergoing TAVI, with an estimated incidence between 2 and 4% [1]. In addition to the occurrence of these ischaemic cerebrovascular events, the number of new cerebral lesions on magnetic resonance imaging after TAVI has been shown to be associated with the occurrence of delirium following TAVI [2]. Moreover, changes in neurocognitive functioning frequently occur after both surgical aortic valve replacement and TAVI [3]. These neurological complications are primarily caused by dislodged material (e.g. pieces of calcium, tissue or thrombus) that embolise towards the brain [4].
In recent years, different catheters have been developed to minimise the risk of neurological complications, such as the filter-based catheter to catch debris in the head and neck vessels and the deflection filter made of fine nitinol that covers all 3 vessels. Observational studies have shown a reduction in the number and volume of cerebral lesions with the use of these embolic protection devices [5]. Last year, the results of the first randomised study looking at hard clinical endpoints were published. The PROTECTED TAVR study, including 3000 patients, confirmed the safety of the filtered-based cerebral protection device but could not demonstrate a reduction in the incidence of stroke [6]. However, a subgroup analysis did show that the use of this filter device reduced the risk of disabling stroke [6]. Another large trial that will randomise 7730 patients to TAVI either with or without a cerebral protection device, the PROTECT-TAVI trial, is currently ongoing [7]. Therefore, a definite answer to whether cerebral protection with the current-generation catheters can prevent stroke in patients undergoing TAVI still has to be awaited.
As mentioned above, ischaemic cerebral lesions due to embolised particles can lead to impaired cognitive functioning. In contrast, TAVI may also have positive cognitive effects as it leads to increased cardiac output and cerebral blood flow [8]. Interestingly, the exact effects of TAVI on cognitive functioning have not been investigated systematically. This has led to the design of the CAPITA (CArdiac outPut, cerebral blood flow and cognition In patients with severe aortic valve stenosis undergoing Transcatheter Aortic valve implantation) study, which is described by Van Nieuwkerk and coworkers in the current issue of the Netherlands Heart Journal [9]. It will be the first large-scale study aimed at prospectively and systematically assessing cognition and cerebral blood flow (CBF) in patients undergoing TAVI. The hypothesis of the study is that improved cardiac output after TAVI results in increased CBF with subsequent positive effects on cognitive functions. Therefore, brain magnetic resonance imaging (measuring CBF) and extensive neuropsychological testing will be performed before and after TAVI (at 3 months and 1 year). The investigators aimed to include 152 patients to prove their hypothesis. The last patient was included in October 2022, and the first study results are expected by the end of 2023. The results of the CAPITA study will teach us about the potential cognitive benefit of TAVI due to improved haemodynamics and enhance our understanding of the relationship between cardiac function, cerebral blood flow and cognitive functioning.
Further expansion of indications for TAVI towards lower-risk and younger patients is expected in the coming years. Therefore, continuous improvements in the TAVI procedure, patient selection and optimal treatment choice are crucial. Whereas trials investigating cerebral protection devices will help to improve clinical outcomes of patients undergoing TAVI, the CAPITA study will lead to better understanding of the heart-brain axis with easier identification of the patient that will benefit the most from TAVI.

Funding

The authors acknowledge the support from the Netherlands Organisation for Health Research and Development (ZonMw).

Conflict of interest

H.M. Aarts and M. Voskuil declare that they have no competing interests.
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://​creativecommons.​org/​licenses/​by/​4.​0/​.
share
DELEN

Deel dit onderdeel of sectie (kopieer de link)

  • Optie A:
    Klik op de rechtermuisknop op de link en selecteer de optie “linkadres kopiëren”
  • Optie B:
    Deel de link per e-mail

Onze productaanbevelingen

Netherlands Heart Journal

Het Netherlands Heart Journal wordt uitgegeven in samenwerking met de Nederlandse Vereniging voor Cardiologie. Het tijdschrift is Engelstalig en wordt gratis beschikbaa ...

Literatuur
1.
go back to reference Vlastra W, Jimenez-Quevedo P, Tchétché D, et al. Predictors, Incidence, and Outcomes of Patients Undergoing Transfemoral Transcatheter Aortic Valve Implantation Complicated by Stroke. Circ Cardiovasc Interv. 2019;12:e7546.CrossRefPubMed Vlastra W, Jimenez-Quevedo P, Tchétché D, et al. Predictors, Incidence, and Outcomes of Patients Undergoing Transfemoral Transcatheter Aortic Valve Implantation Complicated by Stroke. Circ Cardiovasc Interv. 2019;12:e7546.CrossRefPubMed
2.
go back to reference Abawi M, Nijhoff F, Agostoni P, et al. Effect of New Cerebral Ischemic Lesions on the Delirium Occurrence After Transcatheter Aortic Valve Replacement. J Am Coll Cardiol. 2016;68:1489–90.CrossRefPubMed Abawi M, Nijhoff F, Agostoni P, et al. Effect of New Cerebral Ischemic Lesions on the Delirium Occurrence After Transcatheter Aortic Valve Replacement. J Am Coll Cardiol. 2016;68:1489–90.CrossRefPubMed
3.
go back to reference Barber PA, Hach S, Tippett LJ, Ross L, Merry AF, Milsom P. Cerebral Ischemic Lesions on Diffusion-Weighted Imaging Are Associated With Neurocognitive Decline After Cardiac Surgery. Stroke. 2008;39:1427–33.CrossRefPubMed Barber PA, Hach S, Tippett LJ, Ross L, Merry AF, Milsom P. Cerebral Ischemic Lesions on Diffusion-Weighted Imaging Are Associated With Neurocognitive Decline After Cardiac Surgery. Stroke. 2008;39:1427–33.CrossRefPubMed
4.
go back to reference Kroon H, von der Thusen JH. Ziviello F, et al. Heterogeneity of debris captured by cerebral embolic protection filters during TAVI. EuroIntervention. 2021;16:1141–7.CrossRefPubMedPubMedCentral Kroon H, von der Thusen JH. Ziviello F, et al. Heterogeneity of debris captured by cerebral embolic protection filters during TAVI. EuroIntervention. 2021;16:1141–7.CrossRefPubMedPubMedCentral
5.
go back to reference Kroon HG, van der Werf HW, Hoeks SE, et al. Early Clinical Impact of Cerebral Embolic Protection in Patients Undergoing Transcatheter Aortic Valve Replacement. Circ Cardiovasc Interv. 2019;12:e7605.CrossRefPubMed Kroon HG, van der Werf HW, Hoeks SE, et al. Early Clinical Impact of Cerebral Embolic Protection in Patients Undergoing Transcatheter Aortic Valve Replacement. Circ Cardiovasc Interv. 2019;12:e7605.CrossRefPubMed
6.
go back to reference Kapadia SR, Makkar R, Leon M, et al. Cerebral Embolic Protection during Transcatheter Aortic-Valve Replacement. N Engl J Med. 2022;387:1253–63.CrossRefPubMed Kapadia SR, Makkar R, Leon M, et al. Cerebral Embolic Protection during Transcatheter Aortic-Valve Replacement. N Engl J Med. 2022;387:1253–63.CrossRefPubMed
7.
go back to reference Kharbanda RK, Perkins AD, Kennedy J, et al. Routine cerebral embolic protection in transcatheter aortic valve implantation: rationale and design of the randomised British Heart Foundation PROTECT-TAVI trial. EuroIntervention. 2023;18:1428–35.CrossRefPubMed Kharbanda RK, Perkins AD, Kennedy J, et al. Routine cerebral embolic protection in transcatheter aortic valve implantation: rationale and design of the randomised British Heart Foundation PROTECT-TAVI trial. EuroIntervention. 2023;18:1428–35.CrossRefPubMed
8.
go back to reference Schoenenberger AW, Zuber C, Moser A, et al. Evolution of Cognitive Function After Transcatheter Aortic Valve Implantation. Circ Cardiovasc Interv. 2016;9:e3590.CrossRefPubMed Schoenenberger AW, Zuber C, Moser A, et al. Evolution of Cognitive Function After Transcatheter Aortic Valve Implantation. Circ Cardiovasc Interv. 2016;9:e3590.CrossRefPubMed
9.
go back to reference Van Nieuwkerk AC, Hemelrijk KI, Bron EE, et al. Cardiac output, cerebral blood flow and cognition in patients with severe aortic valve stenosis undergoing transcatheter aortic valve implantation: Design and rationale of the CAPITA study. Neth Heart J. 2023. https://doi.org/10.1007/s12471-023-01826-8. Van Nieuwkerk AC, Hemelrijk KI, Bron EE, et al. Cardiac output, cerebral blood flow and cognition in patients with severe aortic valve stenosis undergoing transcatheter aortic valve implantation: Design and rationale of the CAPITA study. Neth Heart J. 2023. https://​doi.​org/​10.​1007/​s12471-023-01826-8.
Metagegevens
Titel
Cognitive function after transcatheter aortic valve implantation: the forgotten child
Auteurs
Hugo M. Aarts
Michiel Voskuil
Publicatiedatum
19-10-2023
Uitgeverij
Bohn Stafleu van Loghum
Gepubliceerd in
Netherlands Heart Journal / Uitgave 12/2023
Print ISSN: 1568-5888
Elektronisch ISSN: 1876-6250
DOI
https://doi.org/10.1007/s12471-023-01821-z

Andere artikelen Uitgave 12/2023

Netherlands Heart Journal 12/2023 Naar de uitgave