Amsterdam Cardiovascular Sciences

In her thesis Astrid van Nieuwkerk highlights significant findings on the cognitive and clinical outcomes of patients with aortic valve stenosis undergoing transcatheter aortic valve implantation (TAVI). The research, based on large international datasets and prospective studies, sheds new light on both the benefits and risks of this increasingly common cardiac procedure.

Cognitive Impairment Overlooked

Cognitive impairment affects about one third of patients with heart failure, coronary artery disease, or aortic valve stenosis, yet often goes unrecognized. “Cognitive deficits often remain unrecognized in clinical practice, despite their negative impact on self-management and treatment adherence,” says Van Nieuwkerk.

Cognitive Benefits After TAVI

Despite well-known risks of periprocedural cerebral emboli, the thesis demonstrates that TAVI can lead to cognitive improvements. “Cerebral blood flow and global cognitive functioning improved three months after TAVI. On a patient level, the majority of patients had stable or improved cognitive functioning” Van Nieuwkerk reports. The greatest cognitive gains were seen in patients with lower baseline cognitive performance. On the other hand, patients with cognitive decline had a higher volume of new white matter intensities on follow-up, an MRI parameter of brain damage. New white matter intensities may be an important, yet relatively unknown, determinant of cognitive deterioration following TAVI. Future research should identify risk factors associated with onset of these white matter hyperintensities and search for preventive strategies.

Stroke Remains a Concern

The thesis reveals that stroke occurred in just over 2% of TAVI patients within 30 days, a rate that has not declined between 2007 and 2022. “The occurrence of stroke was associated with a substantial increase in both short-term and one-year mortality, underscoring the persistent need for prevention and procedural improvements,” Van Nieuwkerk explains.

Clinical Outcomes and Risks

The study also examined other clinical factors. Underweight patients had a higher mortality risk, while diabetes was not linked to worse outcomes. “Major bleeding remained a relevant complication, particularly in women and patients with peripheral vascular disease, but bleeding rates decreased over time,” Van Nieuwkerk notes.

Optimizing Patient Care

The findings emphasize the importance of recognizing cognitive impairment and preventing complications. “TAVI is an effective treatment for severe aortic valve stenosis and safe for cognitive functioning in most patients. Selected patients can even have cognitive benefit from TAVI” concludes Van Nieuwkerk. The thesis calls for continued efforts to identify vulnerable subgroups, particularly those at risk for new white matter hyperintensities, and optimize outcomes for all patients undergoing TAVI.