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Post-TAVR MRI signals risk for silent cerebral microbleeds in some patients
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WASHINGTON — Nearly one-quarter of older patients undergoing transcatheter aortic valve replacement developed silent cerebral microbleeds, according to postprocedure MRI data presented at the American College of Cardiology Scientific Session.
“We are all aware of the potential for silent ischemic strokes after these endovascular procedures, but our study points to the opposite risk — microbleeding — that we have not previously been aware of,” Eric Van Belle, MD, PhD, cardiologist at the Centre Hospitalier Regional in Lille, France, said in a press release. “With more and more endovascular procedures, which require anticoagulants, it could be that these procedures are one of the main triggers of microbleeding seen in the older population. It raises the concern that we may be increasing the risk of this microbleeding with each intervention we perform.”
Van Belle and colleagues performed MRI scans and questionnaire-based neurological tests in 84 patients before and after TAVR with the Sapien valve (Edwards Lifesciences) via femoral delivery. The single-center study was conducted at the Centre Hospitalier Regional.
Preprocedural MRI revealed at least one cerebral microbleed in 26% of patients. At 3 days after TAVR, 40% of patients had microbleeds and 22% had new microbleeds that were not present before TAVR, Van Belle said during a late-breaking clinical trial presentation. Most patients had one microbleed.
Additionally, 5% of patients had evidence of cerebral emboli before TAVR, which increased to 65% after TAVR. At 3 days after the procedure, new cerebral emboli was present in 64% of patients.
Postprocedural stroke or transient ischemic attack occurred in five patients. Of those, two patients had at least one microbleed and all had evidence of cerebral emboli.
“The occurrence of new microbleeds as measured 3 days after the procedure is high, approximately 20%. The presence of microbleeds as detected after the procedure is impacting the 6-month neurological outcome,” Van Belle said.
Questionnaire-based neurological tests were conducted before TAVR and then 3 days and 6 months after TAVR. Microbleeds observed before and after the procedure were associated with deficiencies in thinking and memory. Significant differences included a lower Mini-Mental State Examination (MMSE) score (P = .01) in patients with preprocedural microbleeds and a higher modified Rankin scale score > 1 (P = .008) in the group with postprocedural microbleeds.
Preprocedure microbleeding was significantly more likely in patients with a history of diabetes, hypertension or prior stroke/TIA, whereas postprocedure microbleeding was significantly more likely in those with a history of bleeding.
Patients with microbleeds had longer fluoroscopy time (P = .04), more postdilation (P = .03) and less use of unfractionated heparin plus protamine (P = .04) compared with the group that did not develop new microbleeds. Predictors of new microbleeding, on multivariate analysis, included a prolonged TAVR procedure (RR = 1.21 for every 5-minute increase in fluoroscopy time; 95% CI, 1.01-1.17) and postprocedure-acquired von Willebrand’s disease (RR = 1.42 for every 0.1-U high-molecular-weight multimer ratio; 95% CI, 1.08-1.89), according to data presented.
These findings suggest that further research is warranted to elucidate the causes of microbleeds and to determine whether changes in anticoagulation management can reduce risk, according to Van Belle. He called for systematic MRI investigation in studies evaluating new anticoagulation regimens for patients undergoing TAVR. In addition, the findings demonstrate “the importance of preprocedural cerebral MRI,” he said.
“What we’ve seen in both this and the prior [research] is that very careful pre- and postprocedural assessment, both on MRI and neurologic, is crucial given the complexities of these patients,” Athena Poppas, MD, associate professor of medicine at Brown University and with Rhode Island Hospital, Providence, said during a discussion of the trial. – by Katie Kalvaitis
Reference:
Van Belle E, et al. Joint American College of Cardiology/New England Journal of Medicine Late-Breaking Clinical Trials. Presented at: American College of Cardiology Scientific Session; March 17-19, 2017; Washington, D.C.
Disclosure: Van Belle reports no relevant financial disclosures. Poppas reports financial ties with GE.