Material Type  

 학위논문

 

0017160665

Date and Time of Latest Transaction  

20250211151057

ISBN  

9798382321912

DDC  

610

Author  

Grubman, Daniel.

Title/Author  

Implications of Acute Brain Injury Following Transcatheter Aortic Valve Replacement.

Publish Info  

[S.l.] : Yale University., 2024

Publish Info  

Ann Arbor : ProQuest Dissertations & Theses, 2024

Material Info  

64 p.

General Note  

Source: Dissertations Abstracts International, Volume: 85-11, Section: B.

General Note  

Advisor: Lansky, Alexandra.

학위논문주기  

Thesis (M.D.)--Yale University, 2024.

Abstracts/Etc  

요약Stroke is a feared complication of transcatheter aortic valve replacement (TAVR), affecting 2-8% of patients at 30 days. Beyond clinically evident stroke, covert brain injury (CBI) defined as clinically silent evidence of brain injury on imaging is strikingly prevalent: 70-100% of patients have evidence of new infarcts on diffusion-weighted magnetic resonance imaging (DW-MRI). The clinical significance of these lesions is unknown. Recent guidance has highlighted the importance of imaging in the assessment of cerebral embolic protection (CEP) devices that aim to counter the debris generated during TAVR. This work aims to a) determine the clinical significance of new ischemic lesions, b) propose metrics for ischemic lesion burden, and c) identify factors associated with stroke and CBI, including their association with surgical risk as defined by the Society of Thoracic Surgeons Predicted Risk of Mortality STS score.Patient-level data were pooled from 4 prospective multicenter TAVR studies (DEFLECT III [N=87], NeuroTAVR [N=44], REFLECT I [N=258], and REFLECT II [N=214]). All studies shared a common independent imaging core laboratory and clinical event adjudication committee. DW-MRI were assessed for total lesion number (TLN) per subject, individual lesion volumes (ILV), and total lesion volume (TLV). Receiver operating characteristic (ROC) analysis was performed to identify the optimal DW-MRI measure and thresholds to discriminate ischemic stroke at 30 days.A total of 495 of 603 patients undergoing TAVR completed DW-MRI, with 97% clinical follow-up at 30 days. At 30 days, the rates of death, ischemic stroke, and disabling stroke were 0.8%, 6.9%, and 3.1%. New ischemic lesions were observed in 85% of patients, with a mean TLN of 5.5±7.3 per patient, a mean ILV of 78.2±257.1 mm3 , and a mean TLV of 555±1039 mm3 . The area under the ROC curve was 0.84 for TLV with an optimal cut point of 440 mm3 (Youden criteria) to 547 mm3 (distance 0,1 criteria), 0.82 for maximum ILV (cut point 216 mm3 by both criteria), and 0.81 for TLN (cut point 4-5 lesions). Compared with patients with a TLV ≤500 mm3 , patients with TLV 500mm3 had more ischemic stroke at 30 days (18.2% vs 2.3%, p0.001), more disabling strokes (8.8 vs 0.9%, p0.001), and less complete stroke recovery (44 vs 62.5%, p=0.001). Stroke was independently associated with older age, self-expanding valve use, and worse baseline MoCA and mRS scores. While low (8%) STS PROM predicted mortality at 30 days, stroke rates did not differ across the STS risk groups.This patient-level pooled analysis is the first to demonstrate that acute brain injury measures on DW-MRI can discriminate clinical ischemic stroke and worse recovery in patients undergoing TAVR. A TLV threshold of 500 mm3 had excellent discrimination when categorizing patients with ischemic and disabling stroke. Thresholds of TLN 5 and maximum ILV of 200 mm3 also performed strongly. Our study provides new measures to better predict clinical outcomes of patients undergoing TAVR that will enable better initial evaluation of the efficacy of preventive CEP devices in future trials.

Subject Added Entry-Topical Term  

Medicine.

Subject Added Entry-Topical Term  

Medical imaging.

Subject Added Entry-Topical Term  

Biomedical engineering.

Subject Added Entry-Topical Term  

Health sciences.

Subject Added Entry-Topical Term  

Surgery.

Index Term-Uncontrolled  

Cerebral embolic protection

Index Term-Uncontrolled  

Covert brain injury

Index Term-Uncontrolled  

Magnetic resonance imaging

Index Term-Uncontrolled  

Stroke

Index Term-Uncontrolled  

Transcatheter aortic valve replacement

Added Entry-Corporate Name  

Yale University Yale School of Medicine

Host Item Entry  

Dissertations Abstracts International. 85-11B.

Electronic Location and Access  

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Control Number  

joongbu:658570