经导管主动脉瓣置换术后预期手术风险和卒中及脑损伤风险：一项患者水平的汇总分析

Journal of the Society for Cardiovascular Angiography & Interventions Pub Date : 2025-09-01 DOI:10.1016/j.jscai.2025.103867

Steven R. Messé MD , Daniel Grubman MD , Mary E. Huerter MD , Michael G. Dwyer III PhD , Robert Zivadinov MD, PhD , Cody Pietras BA , Tamim M. Nazif MD , Jeffrey W. Moses MD , Tayyab Shah MD , Louise Gambone RN , Rishi Tripathi MBBS , John K. Forrest MD , Amit N. Vora MD, MPH , Helen Parise ScD , Alexandra J. Lansky MD

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引用次数: 0

摘要

背景：30天胸外科学会预测死亡风险（STS-PROM）已被用于对经导管主动脉瓣置换术（TAVR）患者进行风险分层。手术死亡率是否能预测TAVR术后的脑卒中和神经认知预后尚不清楚。我们评估了STS-PROM与临床结果之间的关系，包括脑卒中、弥散加权磁共振成像（DW-MRI）显示的急性脑损伤以及接受TAVR患者的认知能力下降。方法收集4项前瞻性试验的患者数据：(1)DEFLECT III (N = 87), (2) NeuroTAVR (N = 44), (3) REFLECT I （N = 214）和(4)REFLECT II （N = 258）。所有研究纳入了接受TAVR的患者，并进行了协议规定的出院前DW-MRI和一系列认知和神经学评估。所有患者在基线、术后和30天由委员会认证的神经科医生进行评估。临床结果包括卒中、认知能力下降（蒙特利尔认知评估评分）、死亡、心肌梗死、血管和出血并发症由同一临床事件委员会裁决。成像分析由单一核心实验室使用相同的方法进行。DW-MRI测量包括病变总数、单个病变体积和病变总体积。比较低（STS <4）、中（STS 4-8）和高（STS >8）风险组的结果。结果603例行经股动脉TAVR的DW-MRI和完整STS评估患者中，537例纳入本汇总分析，其中低危253例（47%），中危198例（37%），高危86例（16%）。在30天，高风险患者的全因死亡率和心血管死亡率、心肌梗死、急性肾损伤、出血和血管并发症的发生率更高。中风、致残性中风、DW-MRI测量脑损伤和认知能力下降的发生率在不同的风险类别中相似。结论：本综合分析表明，STS评分不能预测TAVR后卒中、认知能力下降或急性脑损伤。

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Expected Surgical Risk and the Risk of Stroke and Brain Injury After Transcatheter Aortic Valve Replacement: A Patient-Level Pooled Analysis

Background

The 30-day Society of Thoracic Surgeons Predicted Risk of Mortality (STS-PROM) has been used to risk-stratify patients undergoing transcatheter aortic valve replacement (TAVR). Whether surgical mortality risk predicts stroke and neurocognitive outcomes following TAVR is unknown. We evaluated the association between STS-PROM and clinical outcomes, including stroke, acute brain injury on diffusion-weighted magnetic resonance imaging (DW-MRI), and cognitive decline in patients undergoing TAVR.

Methods

Patient-level data were pooled from 4 prospective trials: (1) DEFLECT III (N = 87), (2) NeuroTAVR (N = 44), (3) REFLECT I (N = 214), and (4) REFLECT II (N = 258). All studies included patients undergoing TAVR with a protocol-mandated predischarge DW-MRI and serial cognitive and neurologic assessments. All patients were evaluated by a board-certified neurologist at baseline, postprocedure, and 30 days. Clinical outcomes, including stroke, cognitive decline (Montreal Cognitive Assessment score), death, myocardial infarction, vascular, and bleeding complications were adjudicated by the same clinical events committee. Imaging analysis was performed by a single core laboratory using identical methods. The DW-MRI measures included total lesion number, individual lesion volume, and total lesion volume. Outcomes were compared between low (STS <4), intermediate (STS 4-8), and high (STS >8) risk groups.

Results

In total, 537 of 603 patients with DW-MRI and complete STS assessment undergoing transfemoral TAVR were included in this pooled analysis, of which 253 (47%) were low risk, 198 (37%) intermediate risk, and 86 (16%) high risk patients. At 30 days, high risk patients had higher rates of all-cause and cardiovascular mortality, myocardial infarction, acute kidney injury, bleeding, and vascular complications. Rates of stroke, disabling stroke, DW-MRI measures of brain injury, and cognitive decline were similar across risk categories.