TAVR and cognition

Is there improvement?

Since the revolution that the use of TAVR has brought to valvular heart disease, the elderly patient with aortic stenosis has been studied a lot. What was initially a rescue therapy and almost limited to inoperable patients, today has become a very interesting alternative even for patients at low surgical risk.

Probably the reader must have already faced situations of frail elderly people, in which their attending physician ends up contraindicating a certain cardiac surgery because he believes that there is a great chance that the patient will have a decrease in cognitive standard and this will negatively impact the quality of life of the elderly.

About gains in quality of life and fragility, we recently discussed here on our platform, but what about cognitive pattern specifically?

The large cohort studies that compare TAVR with conventional surgery point to equivalence in the outcome of mortality and disabling stroke. However, several publications indicate a higher risk of silent cerebrovascular events in patients undergoing TAVR due to the release of calcium debris in the great vessels during the passage of guides and introductors.

Although images of the central nervous system point to possible embolic events, the analysis of the cognitive pattern of patients undergoing TAVR in the short term showed significant improvement, most likely due to perfusion improvement by fixedly elevated afterload solution. The only variable that remained independent in this context was the patient’s age, showing that silent embolic events would not have a negative impact on improving the cognitive pattern.

The patients who benefited the most from the improvement in the cognitive standard were exactly those who presented a drop in this item before the procedure. More than 1/3 of the patients with pre-procedure cognitive impairment experienced clinically significant improvement soon after, pointing out that this should not be an exclusion criterion for patients who are candidates for TAVR.

In cases in which there is a drop in cognitive pattern, mainly old memory and visual constructive reasoning were the items affected. Those two criteria are closely related to vascular dementia, pointing to the fact that in some individuals, embolic phenomena can have some relevant clinical impact. Understanding this subgroup can be an important tool to seek protection alternatives, such as devices that filter (although there is still no proven benefit) and even the possibility of using oral anticoagulants, which in some reviews, proved to be protective against central embolic events.

Special attention is required to patients undergoing TAVR who manifest delirium in the immediate postoperative period. Some publications in the field of geriatrics correlate delirium, which is an acute event, with a long-term cognitive decline, and there is still a lack of research aimed at this in patients undergoing TAVR.

Suggested literature:

1 – Gu S, Coakley D, Chan D, et al. Does Transcatheter Aortic Valve Implantation for Aortic Stenosis Impact on Cognitive Function? Cardiol Rev. 2020; 28 (3): 135‐139.

 

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