Eric Van Belle MD-PhD, Nicolas Debry MD et al. Heart Institute

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Presentation transcript:

Silent cerebral microbleeds during TAVR: Insight from a prospective study Eric Van Belle MD-PhD, Nicolas Debry MD et al. Heart Institute CHRU Lille, France

Disclosures : no disclosures Eric Van Belle MD-PhD Nicolas Debry MD Heart and Lung Institute, Lille, France

Cerebral microbleeds (CMB) Extravasations of blood components through fragile cerebral microvascular walls Markers of risk of stroke, dementia and cognitive impairment Endovascular procedures ? Greenberg SM, Vernooij MW, Cordonnier C, Viswanathan A, Al-Shahi Salman R, Warach S, et al. Cerebral microbleeds: a guide to detection and interpretation. Lancet Neurol. 2009 Feb;8(2):165–74.

Silent cerebral emboli TAVR Stroke Silent cerebral emboli ≈65% Long-term cognitive performance preserved 3-5% x 3,5-10 mortality Van Belle E, Hengstenberg C, Lefevre T, Kupatt C, Debry N, Husser O, et al. Cerebral Embolism During Transcatheter Aortic Valve Replacement: The BRAVO-3 MRI Study. J Am Coll Cardiol. 2016.

TAVR Acute changes of haemostasis parameters Correction of the acquired von Willebrand disease -Van Belle E, Rauch A, Vincentelli A, Jeanpierre E, Legendre P, Juthier F, et al. Von Willebrand factor as a biological sensor of blood flow to monitor percutaneous aortic valve interventions. Circ Res. 2015 -Van Belle E, Rauch A, Vincent F, Robin E, Kibler M, Labreuche J, et al. Von Willebrand Factor Multimers during Transcatheter Aortic-Valve Replacement. N Engl J Med. 2016

Cerebral microbleeds (CMB) Incidence ? Outcomes ? (VARC-2) Neurological trajectory ? Mortality ?

Methods 1 2 3 4 5 6 7 Patients referred for TAVR procedure Pre-procedural cerebral MRI : cerebral microbleeds ? 3 Neurological assessment (baseline): NIHSS score, modified Rankin score, EQ-5D scale, MMSE score Analysis of High Molecular Weight(HMW)-multimers of VWF TAVR procedure 4 Post-procedural cerebral MRI : new cerebral microbleeds ? 5 Intrahospital outcomes : VARC-2 criteria 6 Neurological assessment (6 months): NIHSS score, modified Rankin score, EQ-5D scale, MMSE score, QVFS questionnaire 7 Mid-term survival at 12 months

Methods Primary endpoint : appearance and incidence of new cerebral microbleeds on the post-procedural cerebral MRI. Secondary endpoints : presence of microbleed on the preprocedural MRI and cerebral emboli (CE) at preprocedural or post-procedural MRI. Analyses : Identification of predictive factors of primary and secondary endpoints. Evaluation of their impact on early outcomes VARC-2 Impact on the neurological functions examined at 6 months Impact on the global mortality at 1 year follow-up.

Methods Patients referred for TAVR procedure n= 90 patients consented and were enrolled in the study Neurological assessment (preprocedural) NIHSS score, modified Rankin score, EQ-5D scale, MMSE score n = 84 had both MRI and were included in the analysis Preprocedural cerebral MRI n= 22 (26%) patients with at least one CMB; n= 5 (5%) patients with at least one infarct TAVR procedure Postprocedural cerebral MRI n= 19 (23%) patients with at least one new CMB; n= 54 (64%) patients with at least one new infarct Intrahospital outcomes : VARC-2 criteria n= 5 (5% ) intrahospital clinical TIA/strokes Neurological assessment (6 months post TAVR) n= 75 (89%) had a neurological assessment (n= 9 were dead before) Mid-term survival at 1 year n= 73 (86%) were evaluated (n= 11 were dead before)

Results: baseline

Results: procedure and outcomes

Results: predictive factors of CMB a prolonged procedure(RR=1.21 [1.01-1.170] for every increased 5 min of fluoroscopy time, p=0.04) post-procedural acquired-VWD(RR 1.42 [1.08-1.89] for every lower “0.1 unit” of the HMW-multimer-ratio, p=0.004) were associated with the occurrence of new post-procedural microbleed(s).

Results: neurological exam

Conclusions Occurrence of new microbleeds as measured 3 days after the procedure is high (≈20%) Presence of microbleeds as detected after the procedure is impacting the 6-month neurological outcome Procedural management and persistence of acquired-VWD are predictors of the occurrence of microbleeds. Importance of preprocedural Cerebral MRI: 6% of patients had at least one cerebral emboli