Abstract
Chronic silent brain infarctions, detected as new white matter hyperintensities on magnetic resonance imaging (MRI) following transcatheter aortic valve implantation (TAVI), are associated with long-term cognitive deterioration. This is the first study to investigate to which extent the calcification volume of the native aortic valve (AV) measured with cardiac computed tomography angiography (CTA) predicts the increase in chronic white matter hyperintensity volume after TAVI. A total of 36 patients (79 ± 5 years, median EuroSCORE II 1.9%, Q1–Q3 1.5–3.4%) with severe AV stenosis underwent fluid attenuation inversion recovery (FLAIR) MRI < 24 h prior to TAVI and at 3 months follow-up for assessment of cerebral white matter hyperintensity volume (mL). Calcification volumes (mm3) of the AV, aortic arch, landing zone and left ventricle were measured on the CTA pre-TAVI. The largest calcification volumes were found in the AV (median 692 mm3) and aortic arch (median 633 mm3), with a large variation between patients (Q1–Q3 482–1297 mm3 and 213–1727 mm3, respectively). The white matter hyperintensity volume increased in 72% of the patients. In these patients the median volume increase was of 1.1 mL (Q1–Q3 0.3–4.6 mL), corresponding with a 27% increase from baseline (Q1–Q3 7–104%). The calcification volume in the AV predicted the increase of white matter hyperintensity volume (Δ%), with a 35% increase of white matter hyperintensity volume, per 100 mm3 of AV calcification volume (SE 8.5, p < 0.001). The calcification volumes in the aortic arch, landing zone and left ventricle were not associated with the increase in white matter hyperintensity volume. In 72% of the patients new chronic white matter hyperintensities developed 3 months after TAVI, with a median increase of 27%. A higher calcification volume in the AV was associated with a larger increase in the white matter hyperintensity volume. These findings show the potential for automated AV calcium screening as an imaging biomarker to predict chronic silent brain infarctions.
Highlights
Transcatheter aortic valve implantation (TAVI) has been established as an effective treatment of severe aortic valve (AV) stenosis, reducing both clinical symptoms and mortality
We investigated for the first time to which extent the calcification volume of the native aortic valve, aortic arch, landing zone and left ventricle measured with cardiac computed tomography angiography (CTA), can be used to predict the increase in chronic white matter hyperintensities after TAVI, indicating new chronic brain infarctions
The main objectives of the study were to determine the distribution of calcification volumes ( mm3) using CTA in four prespecified sections of the heart and aortic arch of patients undergoing TAVI (Fig. 1) and to determine whether an association exists between the prespecified regional calcification volumes (mm3) and the increase in fluid attenuation inversion recovery (FLAIR)-magnetic resonance imaging (MRI) determined cerebral white matter hyperintensity volume (Δ% from baseline mL), 3 months after TAVI
Summary
Transcatheter aortic valve implantation (TAVI) has been established as an effective treatment of severe aortic valve (AV) stenosis, reducing both clinical symptoms and mortality. One of the most feared complications, namely the occurrence of stroke, is still observed in 2.4% of the patients undergoing TAVI [1]. This complication is observed despite the expansion to low-risk populations, the increase in operator experience and the development of improved valve-systems [2]. Clinically overt strokes are only the tip of the iceberg, since shortly after TAVI acute silent cerebral infarctions are visible with diffusion-weighted magnetic resonance imaging (DW-MRI) in up to 78% of the patients [4]. Currently the majority of the TAVI-induced cerebral emboli remains unpredictable
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