Neurocognitive Functional Assessment After TAVR: Methodologies and Clinical Importance
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1 AORTIC VALVE THERAPIES Today and Tomorrow II September 14, 2014 Neurocognitive Functional Assessment After TAVR: Methodologies and Clinical Importance Ronald M Lazar, PhD, FAHA, FAAN Division of Stroke and Cerebrovascular Disease Tananbaum Stroke Center, Neurological Institute New York Presbyterian Hospital/Columbia University Medical Center
2 Financial Disclosure Affiliation/Financial Relationship Core Lab/Equity Company Claret Medical, Inc
3 Cognition in Operational Terms Language Perception Attention and Concentration Memory Organization Calculation Abstraction Insight and Judgment Decision-Making
4 1.Marshall & Lazar, 2011, 2. Gorelick et al, AHA,2011 Vascular Cognitive Impairment 1 Vascular Dementia Vascular Mild Cognitive Impairment Criteria 2 No Stroke Must be based on Cognitive Testing: At least 4 domains Language Memory Executive Function/Attention/Processing Speed Visual-spatial Function Assumption of decline in at least 1 domain IADL s may be normal or mildly impaired
5 Vascular Cognitive Impairment Cardiovascular Etiologies CABG 1 Atrial Fibrillation/Treatment 2 Congestive Heart Failure/Treatment 3 Carotid Artery Disease/Treatment 4 TAVI/TAVR (?) 1.Selnes et al, Roberts et al, 2010; 2. Elias et al, 2006, Knecht et al, 2008; 3. Vogels et al, 2007; Festa et al, 2011; 4. Heyer et al, 2002, Marshall et al, 2011.
6 Vascular Cognitive Impairment Etiologies of Neurocognitive Dysfunction in Cardiac Disease 1 Small-Vessel Disease Silent Infarction Perfusion Failure/Hypoxia Systemic Sources: Inflammation 1. Gorelick et al, AHA, 2011
7 Impact of Cognitive Impairment Difficulty following instructions Unable to comply with a complex medical protocol Unable to provide informed consent for procedures Difficulty in reacting appropriately to a medical emergency Risk for frank dementia Decreased Quality of Life Increased mortality Consequences e.g., Memory Impairment highly correlated with 30-day re-admission in elderly with CHF (Ketterer, et al, 2014)
8 Does TAVI/TAVR Cause Cognitive Decline from Embolization? (Kahlert et al, Circulation 2010)
9 Figure 1. Detailed analysis of the MMSE results in TAVI patients. N=32 Kahlert P et al. Circulation 2010;121:
10 Vogels et al, Congestive Heart Failure, 2008 Neuropsych HF Cardiac Controls Healthy Controls P Domain (n=43) (n=33) (n=22) MMSE 27.6 (2.1) 27.5 (1.97) 28.1 (1.91).361 Language 0.11 (0.77) 0.04 (0.77) 0.35 (0.71).212 Visuospatial function 0.10 (0.52) 0.15 (0.37) 0.25 (0.70).050 Memory 0.23 (0.60) 0.10 (0.53) 0.27 (0.93).014 Executive function 0.16 (0.56) 0.05 (0.54) 0.33 (0.64).029 Mental speed/attention 0.12 (0.59) 0.08 (0.52) 0.24 (0.75).044 Overall cognitive score 0.14 (0.44) 0.05 (0.38) 0.29 (0.60).003
11 Cognitive Trajectory After Transcatheter Aortic Valve Implantation Ghanem et al, Circ Cardiovasc Interv, 2013 N=111 E1 = Baseline E2 = 3 Days E3 = 90 Days E4 = 1 Yr E5 = 2 Yrs Cognitive Task: RBANS RESULTS: No change in cognition over time No association with cerebral embolism on DWI. COMMENT: Lack of Sensitivity and Specificity in RBANS Baseline significantly lower than normals (82) 27% with MCI (Mean = SD)* No practice effect at 3 or 90 days *AD Mean = SD (RBANS manual)
12 Comprehensive Prospective Cognitive and Physical Function Assessment in Elderly Patients Undergoing Transcatheter Aortic Valve Implantation Orvin et al, Cardiology, 2014 N=36/44 Mean Age = 82 years old Exams: Baseline and 30 days RESULTS: Improved functional status and valve hemodynamics No aspect of cognition or QoL worsened and some improved. Comment: Post-TAVR improvement: Increase in CBF or Practice Effects? Cognistat: Less sensitive than full exam after stroke (Nøkleby et al, 2008) No imaging
13 Conclusions The questions regarding neurocognition after TAVR/TAVI remain unanswered. Neurocognitive batteries need to be comprehensive with good sensitivity and specificity to the underlying pathology. Imaging should take advantage of the more powerful 3.0 Tesla technology, both for DWI in the acute stage and FLAIR in the chronic period. Baseline assessments need to take into consideration the impact of the disease before treatment, including brain perfusion.
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