Silent Brain Infarction, Delirium, and Cognition in Three Invasive Cardiovascular Procedures: a Systematic Review

Risk factors and prognosis of silent cerebral infarction after transcatheter aortic valve replacement

The Valve Academic Research Consortium (VARC)-3 definition of silent cerebral infarction among neurologic events after transcatheter aortic valve replacement (TAVR) lacks clinical validation, yet its impact on postoperative in-hospital outcomes and long-term prognosis remains uncertain. This study aims to explore the perioperative related factors influencing the risk of SCI post-TAVR as defined by VARC-3 criteria, so as to identify high-risk individuals early and assess the effect of SCI on patient outcomes and one-year mortality following TAVR. This was a single-center study including 613 patients with severe aortic stenosis undergoing TAVR, with all data collected prospectively in a dedicated database.We compared clinical baseline data, preoperative imaging results, perioperative factors, and intraoperative variables between patients with and without SCI according to VARC-3. Multivariate logistic regression was used to identify risk factors associated with SCI. Propensity score matching (PSM) at a 1:2 ratio was employed based on fundamental characteristics such as age, gender, BMI, and medical history to minimize potential confounding. Post-matching, we analyzed differences in postoperative in-hospital outcomes and other results between the two groups. Survival times were compared using the Kaplan-Meier method, and survival curves were plotted. The log-rank test assessed statistical differences between the survival curves. Furthermore, univariate and multivariate Cox regression analyses were conducted to determine risk factors for one-year postoperative mortality. Out of 827 TAVR patients screened, 613 were included in the final analysis-471 in the SCI group and 142 in the non-SCI group-resulting in an incidence rate of 76.8% for SCI. The occurrence of post-induction hypotension was significantly higher in the SCI group compared to the non-SCI group (70.28% vs. 61.27%, P = 0.043). Multivariate logistic regression revealed that post-induction hypotension lasting less than 10 min (odds ratio [OR]: 1.73; 95% confidence interval [CI]: 1.13-3.26; P = 0.009), hypotension lasting more than 10 min (OR: 1.98; 95% CI: 1.18-3.33; P = 0.01), and postoperative tachyarrhythmia (OR: 1.98; 95% CI: 1.27-3.07; P = 0.002) were significant risk factors for developing SCI after TAVR. Following 1:2 PSM, 416 patients remained-274 in the SCI group and 142 in the non-SCI group. After matching, the SCI group had a notably higher incidence of postoperative delirium compared to the non-SCI group (9.12% vs. 2.82%; P = 0.017), and their one-year mortality rate was also elevated (5.47% vs. 0.70%; P = 0.016). Additionally, multivariate Cox regression analysis indicated that elevated preoperative creatinine levels (hazard ratio [HR]: 1.01; 95% CI: 1.01-1.02; P = 0.011), presence of SCI (HR: 10.81; 95% CI: 1.31-89.18; P = 0.027), Society of Thoracic Surgeons (STS) score greater than 7% (HR: 3.32; 95% CI: 1.07-10.33; P < 0.038), age 75 years or older (HR: 7.86; 95% CI: 1.01-14.47; P = 0.049), and a history of stroke (HR: 7.20; 95% CI: 2.32-22.35; P < 0.001) were independent risk factors for one-year mortality post-TAVR. Our findings suggest that post-induction hypotension and postoperative tachyarrhythmia are significant risk factors for SCI following TAVR as defined by VARC-3 criteria. Patients who developed SCI after TAVR exhibited higher rates of postoperative delirium and increased one-year mortality compared to those without this complication. Furthermore, factors such as elevated preoperative creatinine levels, an STS score above 7%, age of 75 years or older, and a prior history of stroke were associated with higher one-year mortality rates after TAVR. Given the negative impact of occult SCI on clinical outcomes, every effort should be made to reduce the risk of neurological complications after TAVR.

Incidence of silent cerebral events detected by MRI in patients with atrial fibrillation undergoing pulsed field ablation vs thermal ablation: A systematic review and network meta-analysis

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, and catheter ablation has been demonstrated to achieve superior success rates compared with antiarrhythmic drugs. However, this procedure entails certain risks, including silent cerebral events (SCEs), which may affect cognitive function. This network meta-analysis aimed to determine the global incidence of SCEs in patients with AF undergoing catheter ablation and to compare the incidence across energy sources and catheter types. Our analysis included 86 trials involving 10,456 patients with AF, with a pooled SCE incidence of 19.1%. For pulsed field ablation, the incidence of SCEs was 14.4%; thermal ablation techniques showed rates of 17.7% for radiofrequency ablation, 20.8% for cryoballoon ablation, and 32.7% for laser ablation. No significant differences were found between pulsed field ablation and thermal ablation in SCE incidence. The comparison of SCE incidence between different catheter types revealed variations. The HD Mesh Ablator demonstrated the lowest incidence rate (15.1%), whereas the PVAC catheter had the highest (36.2%). The Farawave catheter had an incidence rate of 18.5% and showed no significant differences compared with most thermal catheters, except for the HD Mesh Ablator (relative risk, 0.15; 95% credible interval, 0.03-0.89). Our findings indicate that a substantial proportion of patients experience SCEs after catheter ablation for AF, with an overall incidence of approximately 19.1% occurring within 1 week (mostly within 72 hours) after ablation. No significant differences were observed in SCE incidence between pulsed field ablation and thermal ablation or between the Farawave catheter and most thermal catheters.

Exploring the Link between Anticoagulation, Cognitive Impairment and Dementia in Atrial Fibrillation: A Systematic Review

Background: The impact of oral anticoagulants (OACs) on cognitive impairment and dementia in patients with atrial fibrillation (AF) is not well characterized. This systematic review aims to address this knowledge gap. Methods: SCOPUS and PubMed searches were conducted to identify articles in the English language investigating the association between the use of OACs and cognitive impairment and dementia. We excluded non-original research studies and studies that did not report data on cognitive impairment or included patients who underwent open heart surgery or had psychiatric illnesses or cancer. Results: Out of 22 studies (n = 606,404 patients), 13 studies (n = 597,744 patients) reported a reduction in cognitive impairment/dementia in those undergoing thromboprophylaxis. Using direct oral anticoagulants (DOACs) was associated with a lower incidence of cognitive impairment in 10 studies (n = 284,636 patients). One study found that patients undergoing dual therapy (n = 6794 patients) had a greater incidence of cognitive impairment compared to those undergoing monotherapy (n = 9994 patients). Three studies (n = 61,991 patients) showed that AF patients on DOACs had a lower likelihood of dementia diagnosis than those on vitamin K antagonists (VKAs). Dementia incidence was lower when VKAs were under good control. Conclusions: The use of oral anticoagulants has the potential to prevent cognitive impairment and dementia in patients with AF. Since most of the published research on this subject is observational in nature, more randomized controlled trials are needed to fully understand the effect of anticoagulants on cognitive function.

[History of anti-embolic protection in cardiac surgery]

The review is devoted to history of anti-embolic protection system, in particular protection against cerebral embolism, in cardiac surgery and endovascular surgery. Cerebral embolism is a common and dangerous complication in cardiovascular surgery, leading to disability of patients and significantly impairing treatment outcomes. Prevention of embolic complications is an urgent task in correction of heart valve disease in cardiac and endovascular surgery.

Iatrogenic Strokes and Covert Brain Infarcts After Percutaneous Cardiac Procedures: An Update

Millions of cardiac procedures are performed worldwide each year, making the potential complication of periprocedural iatrogenic stroke an important concern. These strokes can occur intraoperatively or within 30 days of a procedure and can be categorised as either overt or covert, occurring without obvious acute neurologic symptoms. Understanding the prevalence, risk factors, and strategies for preventing overt and covert strokes associated with cardiac procedures is imperative for reducing periprocedural morbidity and mortality. In this narrative review, we focus on the impacts of perioperative ischemic strokes for several of the most common interventional cardiac procedures, their relevance from a neurologic standpoint, and future directions for the care and research on perioperative strokes. Depending on the percutaneous procedure, the rates of periprocedural overt strokes can range from as little as 0.01% to as high as 2.9%. Meanwhile, covert brain infarctions (CBIs) occur much more frequently, with rates for different procedures ranging from 10%-84%. Risk factors include previous stroke, atherosclerotic disease, carotid stenosis, female sex, and African race, as well as other patient- and procedure-level factors. While the impact of covert brain infarctions is still a developing field, overt strokes for cardiac procedures lead to longer stays in hospital and increased costs. Potential preventative measures include screening and vascular risk factor control, premedicating, and procedural considerations such as the use of cerebral embolic protection devices. In addition, emerging treatments from the neurologic field, including neuroprotective drugs and remote ischemic conditioning, present promising avenues for preventing these strokes and merit investigation in cardiac procedures.