Clinical Significance of Diffusion-Weighted Brain MRI Lesions After TAVR: Results of a Patient-Level Pooled Analysis,Journal of the American College of Cardiology

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Clinical Significance of Diffusion-Weighted Brain MRI Lesions After TAVR: Results of a Patient-Level Pooled Analysis
Journal of the American College of Cardiology ( IF 21.7 ) Pub Date : 2024-08-12 , DOI: 10.1016/j.jacc.2024.05.055
Alexandra J Lansky ₁ , Daniel Grubman ₁ , Michael G Dwyer ₂ , Robert Zivadinov ₂ , Helen Parise ₁ , Jeffrey W Moses ₃ , Tayyab Shah ₄ , Cody Pietras ₁ , Daniela Tirziu ₁ , Louise Gambone ₁ , Martin B Leon ₅ , Tamim M Nazif ₆ , Steven R Messé ₇

Affiliation

Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA; Yale Cardiovascular Research Group, New Haven, Connecticut USA.
Buffalo Neuroimaging Analysis Center, Department of Neurology, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York, USA; Center for Biomedical Imaging, University at Buffalo, State University of New York, Buffalo, New York, USA.
NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York, USA; St. Francis Hospital & Heart Center, Roslyn, New York, 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; Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York, USA; Cardiovascular Research Foundation, New York, New York, USA.
NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York, USA.
Division of Cardiology, Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.

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%; < 0.0001), more disabling strokes (8.8% vs 0.9%; < 0.0001), and less complete stroke recovery (44% vs 62.5%; = 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]; ) (A Study to Evaluate the Neuro-embolic Consequences of TAVR [NeuroTAVR]; ) (The REFLECT Trial: Cerebral Protection to Reduce Cerebral Embolic Lesions After Transcatheter Aortic Valve Implantation [REFLECT I]; ) (The REFLECT Trial: Cerebral Protection to Reduce Cerebral Embolic Lesions After Transcatheter Aortic Valve Implantation [REFLECT II]; )

更新日期：2024-08-12

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