Meta-Analysis of Prevalence and Risk Factors for Cognitive Decline and Improvement After Transcatheter Aortic Valve Implantation

Abstract

Changes to cognition, both decline and improvement, are commonly reported after transcatheter aortic valve implantation (TAVI). However, previous systematic reviews and meta-analyses have missed these subgroups by assessing whole-group-averages for cognitive outcomes. We sought to pool estimates to identify the prevalence of cognitive decline and improvement after TAVI, as well as associated factors for these outcomes. A systematic review identified 15 articles appropriate for meta-analysis. When robust cognitive change definitions were employed, the pooled prevalence of incident cognitive impairment up to 1-, 1 to 6-, and ≥6-months post-TAVI was 7%, 14%, and 12%, respectively. For cognitive improvement, the prevalence from 1 to 6 months and ≥6 months after TAVI was estimated to be 19% and 11%, respectively. Two factors were associated with these cognitive outcomes: (1) using a cerebral embolic protection device was associated with decreased prevalence of cognitive decline up to 1-week post-TAVI; (2) baseline cognitive impairment had a large association with post-TAVI cognitive improvement. In conclusion, cognitive decline and cognitive improvement are experienced by approximately 7% to 19% of patients after TAVI, respectively. Those with the lowest cognitive performance pre-TAVI appear to have the most to gain in terms of cognitive improvement post-TAVI. Identifying further predictive factors for cognitive decline and improvement post-TAVI will facilitate a personalized-medicine approach for cognitive care and prognosis. Changes to cognition, both decline and improvement, are commonly reported after transcatheter aortic valve implantation (TAVI). However, previous systematic reviews and meta-analyses have missed these subgroups by assessing whole-group-averages for cognitive outcomes. We sought to pool estimates to identify the prevalence of cognitive decline and improvement after TAVI, as well as associated factors for these outcomes. A systematic review identified 15 articles appropriate for meta-analysis. When robust cognitive change definitions were employed, the pooled prevalence of incident cognitive impairment up to 1-, 1 to 6-, and ≥6-months post-TAVI was 7%, 14%, and 12%, respectively. For cognitive improvement, the prevalence from 1 to 6 months and ≥6 months after TAVI was estimated to be 19% and 11%, respectively. Two factors were associated with these cognitive outcomes: (1) using a cerebral embolic protection device was associated with decreased prevalence of cognitive decline up to 1-week post-TAVI; (2) baseline cognitive impairment had a large association with post-TAVI cognitive improvement. In conclusion, cognitive decline and cognitive improvement are experienced by approximately 7% to 19% of patients after TAVI, respectively. Those with the lowest cognitive performance pre-TAVI appear to have the most to gain in terms of cognitive improvement post-TAVI. Identifying further predictive factors for cognitive decline and improvement post-TAVI will facilitate a personalized-medicine approach for cognitive care and prognosis. Since its introduction in 2002, transcatheter aortic valve implantation (TAVI) has become standard care for severe symptomatic aortic stenosis in patients not suitable for surgical aortic valve replacement.1Leon MB Smith CR Mack M Miller DC Moses JW Svensson LG Tuzcu EM Webb JG Fontana GP Makkar RR Brown DL Block PC Guyton RA Pichard AD Bavaria JE Herrmann HC Douglas PS Petersen JL Akin JJ Anderson WN Wang D Pocock S Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery.N Engl J Med. 2010; 363: 1597-1607Crossref PubMed Scopus (5249) Google Scholar TAVI has shown increased survival and reduced all-cause mortality compared with the surgical alternative, as well as long-term improvements in quality of life and functional capabilities.1Leon MB Smith CR Mack M Miller DC Moses JW Svensson LG Tuzcu EM Webb JG Fontana GP Makkar RR Brown DL Block PC Guyton RA Pichard AD Bavaria JE Herrmann HC Douglas PS Petersen JL Akin JJ Anderson WN Wang D Pocock S Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery.N Engl J Med. 2010; 363: 1597-1607Crossref PubMed Scopus (5249) Google Scholar, 2Adams DH Popma JJ Reardon MJ Yakubov SJ Coselli JS Deeb GM Gleason TG Buchbinder M Hermiller Jr, J Kleiman NS Chetcuti S Heiser J Merhi W Zorn G Tadros P Robinson N Petrossian G Hughes C Harrison K Conte J Maini B Mumtaz M Chenoweth S Oh JK Transcatheter aortic-valve replacement with a self-expanding prosthesis.N Engl J Med. 2014; 370: 1790-1798Crossref PubMed Scopus (1945) Google Scholar, 3Georgiadou P Kontodima P Sbarouni E Karavolias GK Smirli A Xanthos T Troupis T Khouri M Papadimitriou L Voudris V Long-term quality of life improvement after transcatheter aortic valve implantation.Am Heart J. 2011; 162: 232-237Crossref PubMed Scopus (36) Google Scholar Previous systematic review and meta-analyses of cognitive outcomes after TAVI have shown, at a group-level, preservation (i.e., no significant decline or improvement) of cognitive function after TAVI.4Khan MM Herrmann N Gallagher D Gandell D Fremes SE Wijeysundera HC Radhakrishnan S Sun YR Lanctot KL Cognitive outcomes after transcatheter aortic valve implantation: a metaanalysis.J Am Geriatr Soc. 2018; 66: 254-262Crossref PubMed Scopus (20) Google Scholar,5Lai KSP Herrmann N Saleem M Lanctôt KL Cognitive outcomes following transcatheter aortic valve implantation: a systematic review.Cardiovasc Psychiatry Neurol. 2015; 2015Crossref PubMed Scopus (14) Google Scholar However, not all patient experiences align with this conclusion. Individual studies report a variety of cognitive outcomes (decline, no change, and improvement) experienced after TAVI.6Ghanem A Kocurek J Sinning J-M Wagner M Becker BV Vogel M Schröder T Wolfsgruber S Vasa-Nicotera M Hammerstingl C Schwab JO Thomas D Werner N Grube E Nickenig G Muller A Cognitive trajectory after transcatheter aortic valve implantation.Circ Cardiovasc Interv. 2013; 6: 615-624Crossref PubMed Scopus (72) Google Scholar, 7Orvin K Dvir D Weiss A Assali A Vaknin-Assa H Shapira Y Gazit O Sagie A Kornowski R Comprehensive prospective cognitive and physical function assessment in elderly patients undergoing transcatheter aortic valve implantation.Cardiology. 2014; 127: 227-235Crossref PubMed Scopus (17) Google Scholar, 8Kahlert P Al-Rashid F Döttger P Mori K Plicht B Wendt D Bergmann L Kottenberg E Schlamann M Mummel P Holle D Thielmann M Jakob HG Konorza T Heusch G Erbel R Eggebrecht H Cerebral embolization during transcatheter aortic valve implantation: a transcranial Doppler study.Circulation. 2012; 126: 1245-1255Crossref PubMed Scopus (246) Google Scholar, 9Knipp SC Kahlert P Jokisch D Schlamann M Wendt D Weimar C Jakob H Thielmann M Cognitive function after transapical aortic valve implantation: a single-centre study with 3-month follow-up.Interact Cardiovasc Thorac Surg. 2013; 16: 116-122Crossref PubMed Scopus (47) Google Scholar, 10Rodés-Cabau J Dumont E Boone RH Larose E Bagur R Gurvitch R Bédard F Doyle D De Larochellière R Jayasuria C Villeneuve J Marrero A Cote M Pibarot P Webb JG Cerebral embolism following transcatheter aortic valve implantation: comparison of transfemoral and transapical approaches.J Am Coll Cardiol. 2011; 57: 18-28Crossref PubMed Scopus (244) Google Scholar Knowledge of which patients are expected to cognitively decline and improve after TAVI is clinically relevant and important. This systematic review and meta-analysis synthesized existing literature to provide estimates of the prevalence of cognitive decline and improvement after TAVI. Additionally, an analysis of reported risk factors for cognitive decline and protective factors for cognitive improvement was conducted. This review was conducted in adherence with the Preferred Reporting Items for Systematic reviews and Meta-Analysis statement.11Liberati A Altman DG Tetzlaff J Mulrow C Gøtzsche PC Ioannidis JPA Clarke M Devereaux PJ Kleijnen J Moher D The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration.Ann Intern Med. 2009; 151: W-65-W-94Crossref Scopus (3902) Google Scholar Abstract, full-text screening and data extraction were conducted by 2 independent reviewers (E.S. Ghezzi and T.J. Ross). Conflicts were resolved through discussion. PsycINFO, Ovid Emcare, EMBASE, Pubmed, and Cochrane databases were searched using the search terms listed in the Supplement. Studies published from the time of the first TAVI procedure in 2002 until the search date (November 27, 2019) were included. Inclusion criteria were peer-reviewed, full-text, English language studies investigating adult participants who underwent a TAVI procedure. Studies had to include both a pre- and postprocedure cognitive measure and report the number of participants who declined and/or improved post-TAVI relative to preprocedure cognitive function. Studies were excluded if only group-level changes to cognition were reported (i.e., average cognitive score pre- and post-TAVI), and if only mixed-samples were reported (e.g., TAVI and surgical aortic valve replacement). Case studies (n = 1), dissertations, book chapters, protocol papers, reviews, news articles, conference abstracts, letters to the editor, editorials and commentary publications were also excluded. The quality of evidence and risk of bias were assessed using the Joanna Briggs Institute Critical Appraisal Checklist for Studies Reporting Prevalence Data12Joanna Briggs InstituteJoanna Briggs Institute Critical Appraisal Checklist for Studies Reporting Prevalence Data. Joanna Briggs Institute, Adelaide2011Google Scholar (Supplement Table 1). Data extracted included country, sample size, age, gender, definition of cognitive decline/improvement, frequency of cognitive decline/improvement at reported time-points post-TAVI, and reported predictive factors (pre-, intra-, and postoperative variables) for cognitive decline and improvement. Cognitive decline or improvement based on all cognitive assessments were included, from global cognitive function assessments (e.g., Montreal Cognitive Assessment [MoCA], Mini Mental State Examination [MMSE]) to individual tests (e.g., Trail Making Test, Digit Substitution Test, etc.). When 1 study reported 2 methods of determining cognitive decline within the same participants (e.g., decline in MoCA or MMSE), data from both methods were averaged within analyses. Meta-analyses were completed using the Comprehensive Meta-Analysis Software (Version 3).13Borenstein M, Hedges L, Higgins J, Rothstein H. Comprehensive Meta-Analysis Version 3, 2013, Englewood, NJ: Biostat.Google Scholar Random-effects modelling was used due to considerable heterogeneity in study sample and design of included studies. Heterogeneity was assessed using the I2 statistic, with values of 25%, 50%, and 75% interpreted as small, moderate and large, respectively.14Higgins JP Thompson SG Deeks JJ Altman DG Measuring inconsistency in meta-analyses.BMJ. 2003; 327: 557-560Crossref PubMed Scopus (37388) Google Scholar Cognitive decline and improvement data were separated into 3 time-points post-TAVI: <1 month; ≥1 month and <6 months; and ≥6 months. Meta-analyses were then conducted to estimate prevalence of cognitive decline and cognitive improvement at each time-point. When 1 study reported 2 data points within 1 time period analysis (e.g., 2 and 7 days are both <1 month), both time points (measuring the same sample of participants) were averaged within analyses. We further split these prevalence estimates by categorizing each study-reported definition of cognitive change (e.g., cognitive decline defined as ≥20% decrease in MoCA score) as relaxed or robust. Cognitive change definitions were categorized as relaxed if they did not attempt to account for measurement error or bias; simply counting any baseline to post-TAVI as a relevant change, of cognitive decline or improvement. defined robust cognitive change definitions as which to account for score in through a standard A Kocurek J Sinning J-M Wagner M Becker BV Vogel M Schröder T Wolfsgruber S Vasa-Nicotera M Hammerstingl C Schwab JO Thomas D Werner N Grube E Nickenig G Muller A Cognitive trajectory after transcatheter aortic valve implantation.Circ Cardiovasc Interv. 2013; 6: 615-624Crossref PubMed Scopus (72) Google SC Kahlert P Jokisch D Schlamann M Wendt D Weimar C Jakob H Thielmann M Cognitive function after transapical aortic valve implantation: a single-centre study with 3-month follow-up.Interact Cardiovasc Thorac Surg. 2013; 16: 116-122Crossref PubMed Scopus (47) Google Scholar a change A C G P M V C A A A R H P J D after transcatheter aortic valve implantation compared with surgical aortic valve replacement in risk Cardiol. PubMed Scopus Google V F A M O C R JG De Larochellière R Doyle D Dumont E S Cote M Marrero A R J changes in cognitive function following transcatheter aortic valve Am Coll Cardiol. PubMed Scopus Google Scholar or a score change baseline to on a cognitive (e.g., MoCA or of JP DL C S J C S M cerebral during transcatheter aortic valve Thorac Surg. PubMed Scopus Google Scholar, JP DL EM DG Clarke C O in transcatheter aortic valve Am Heart PubMed Scopus Google Scholar, TG DH Reardon MJ Kleiman NS Conte Deeb GM Hughes Jr, Chenoweth S Popma JJ The risk and of are for patients with transcatheter or surgical aortic valve Thorac Cardiovasc Surg. PubMed Scopus Google Scholar, C A M P S T S of cognitive function after transcatheter aortic valve implantation.Circ Cardiovasc Interv. PubMed Scopus Google Scholar to estimate the prevalence of cognitive decline or improvement based on cognitive change definition and were conducted at each for which 2 or reported cognitive factors were synthesized in the meta-analysis if they had reported in at 2 of the included studies. independent risk factors this The outcomes are for risk factors and for risk of the or was by a for each A of articles were after were and criteria for full-text review and 15 of these were included for review and meta-analyses (Supplement 1). 15 studies reported of cognitive decline post-TAVI and of these reported the of cognitive improvement post-TAVI 1 and for of these of included studies which report cognitive decline following transcatheter aortic valve study in of assessment reported within the study at at in reported as or decline sample = Cognitive score number of tests with improvement and decline = = = Digit Substitution = cognitive = 1 = Digit 2 = = Mini Mental State MoCA = Montreal Cognitive = for the Assessment of = change = of TAVI = transcatheter aortic valve = Trail Making = Trail Making = sample = Cognitive score number of tests with improvement and decline = = = Digit Substitution = cognitive = 1 = Digit 2 = = Mini Mental State MoCA = Montreal Cognitive = for the Assessment of = change = of TAVI = transcatheter aortic valve = Trail Making = Trail Making = 1 1 and 1 1 in 1 sample = Cognitive score number of tests with improvement and decline = = = Digit Substitution = cognitive = 1 = Digit 2 = = Mini Mental State MoCA = Montreal Cognitive = for the Assessment of = change = of TAVI = transcatheter aortic valve = Trail Making = Trail Making = sample = Cognitive score number of tests with improvement and decline = = = Digit Substitution = cognitive = 1 = Digit 2 = = Mini Mental State MoCA = Montreal Cognitive = for the Assessment of = change = of TAVI = transcatheter aortic valve = Trail Making = Trail Making = 1 and in 1 sample = Cognitive score number of tests with improvement and decline = = = Digit Substitution = cognitive = 1 = Digit 2 = = Mini Mental State MoCA = Montreal Cognitive = for the Assessment of = change = of TAVI = transcatheter aortic valve = Trail Making = Trail Making = study in in reported as or reported within the study sample = Cognitive score number of tests with improvement and decline = = = Digit Substitution = cognitive = 1 = Digit 2 = = Mini Mental State MoCA = Montreal Cognitive = for the Assessment of = change = of TAVI = transcatheter aortic valve = Trail Making = Trail Making = in a Table of included studies which report cognitive improvement following transcatheter aortic valve study in of assessment reported within the study at at in reported as or = Digit Substitution = cognitive = = Mini Mental State MoCA = Montreal Cognitive = change TAVI = transcatheter aortic valve = Trail Making = Trail Making = improvement in 1 in 1 3 study in reported within the study in reported as or = Digit Substitution = cognitive = = Mini Mental State MoCA = Montreal Cognitive = change TAVI = transcatheter aortic valve = Trail Making = Trail Making = in a The pooled prevalence of cognitive decline of was to I2 = up to 1 to I2 = from 1 to 6 and 7% to I2 = 6 months and after TAVI 1). The pooled prevalence of cognitive improvement was to I2 = from 1 to 6 months of and to I2 = 6 months and on robust after TAVI 1). The prevalence of cognitive improvement up to 1 month after TAVI was not as only 1 Brown D C H S M P Petrossian G S Moses J JK of transcatheter aortic valve implantation the J Cardiol. PubMed Scopus Google Scholar reported relevant data cognitive improvement at The pooled prevalence of cognitive decline up to post-TAVI using a relaxed cognitive change definition was to I2 = 7% to I2 = a robust cognitive change definition was 1). The pooled prevalence of cognitive decline 1 to 6 months post-TAVI using a relaxed cognitive change definition was to I2 = and to I2 = a robust cognitive change definition was 1). The pooled prevalence of cognitive improvement 1 to 6 months post-TAVI using a relaxed cognitive change definition was to I2 = and 19% to I2 = a robust cognitive change definition was used 1). and heterogeneity for prevalence be in Table 2 and Table risk factors for the of cognitive decline after TAVI were Table 3 and Table factors gender, baseline cognitive and 1 protection and 1 data were to split the risk analysis for cerebral protection device into 2 up to and post-TAVI; all data were on intra-, and for the of cognitive decline and cognitive improvement following transcatheter aortic valve of or associated with cognitive decline 2013; = = = 2013; 2015; = = = 2013; = = = 2013; = = 2013; = = = 2013; = = = 2013; = = = 2013; = = = Cerebral protection 2015; to = = = Cerebral protection = = = patients had a or based on within based on = = cognitive = = = = = = associated with cognitive improvement = = = patients had a or based on within based on = = cognitive = = = in a a cerebral protection device was associated with prevalence of cognitive decline up to 1-week post-TAVI to = However, at post-TAVI, using a cerebral protection device was not associated with prevalence of cognitive decline to = factors were associated with cognitive factors for cognition after TAVI were not commonly The only that was reported by 1 was baseline cognitive baseline cognitive impairment was the for the of cognitive improvement Table 3 and Table with the association to be significant to This meta-analysis synthesized data cognitive decline and improvement in TAVI patients Studies using relaxed definitions of cognitive change not account for measurement error and the and of both cognitive decline and improvement. account for individual in cognitive tests estimates for prevalence of cognitive decline and improvement after TAVI from robust cognitive change report that estimates of prevalence of cognitive decline up to 1 to and ≥6-months post-TAVI are 7%, 14%, and 12%, For cognitive improvement, the prevalence from 1 to 6 and ≥6 months after TAVI is estimated at 19% and 11%, be these as pooled estimates are not time-points and cognitive decline and improvement they to that cognitive decline and improvement are both commonly outcomes after TAVI with of cognitive decline and improvement estimated to be 7% and 19% in the 6 months after TAVI. as of TAVI patients cognitive decline and cognitive improvement, which has to the using a approach MM Herrmann N Gallagher D Gandell D Fremes SE Wijeysundera HC Radhakrishnan S Sun YR Lanctot KL Cognitive outcomes after transcatheter aortic valve implantation: a metaanalysis.J Am Geriatr Soc. 2018; 66: 254-262Crossref PubMed Scopus (20) Google Scholar,5Lai KSP Herrmann N Saleem M Lanctôt KL Cognitive outcomes following transcatheter aortic valve implantation: a systematic review.Cardiovasc Psychiatry Neurol. 2015; 2015Crossref PubMed Scopus (14) Google Scholar However, is that to the heterogeneity in this at risk of cognitive decline and improvement post-TAVI. the predictive factors for cognitive decline and improvement, provide care and improve prognosis. We reporting of risk factors for cognitive decline after TAVI in the were only to the of factors on to cognitive the only of a cerebral protection device was to have a significant association with prevalence of cognitive decline up to 1-week post-TAVI, which was no significant at 1 patients in these studies used a protection device or did patient have these Cognitive improvement is a after TAVI, in an estimated 19% of patients up to cognitive impairment was the only to be and was to have a large association with post-TAVI cognitive improvement. Those with the lowest cognitive function pre-TAVI have the most to gain post-TAVI; also be the that within of the tests used in studies this a large of the A S D H A A S H outcomes of transcatheter surgical aortic valve replacement in Cardiovasc Interv. 2018; PubMed Scopus Google Scholar who underwent TAVI with preprocedure cognitive impairment S S A P T C M S S P of functional decline in elderly patients undergoing transcatheter aortic valve implantation Heart J. 2013; PubMed Scopus Google Scholar, S A B P T S S P of assessment as a of mortality and after transcatheter aortic valve Cardiovasc Interv. 2012; PubMed Scopus Google Scholar, L following transcatheter aortic valve implantation: a J 2015; PubMed Scopus Google Scholar these is for cognitive improvement after TAVI in these reporting of risk factors the of on cognitive outcomes after TAVI were to be This of on of cognitive decline post-TAVI is a meta-analysis which identified risk factors for after E PJ T DH Harrison S of prevalence and risk factors for after transcatheter aortic valve implantation.Am J Cardiol. 2018; PubMed Scopus Google Scholar is incident cognitive which is TG D A The and in elderly Neurol. 2015; PubMed Scopus Google Scholar the of risk factors identified for transapical and E PJ T DH Harrison S of prevalence and risk factors for after transcatheter aortic valve implantation.Am J Cardiol. 2018; PubMed Scopus Google Scholar on post-TAVI cognitive decline be in studies. of risk factors identified for cognitive decline after Ghezzi Smith factors for and cognitive decline following a systematic review and Scholar in to post-TAVI cognitive outcomes also be will a analysis of the of cognitive decline and improvement after TAVI. be that 3 of the reported risk factors for after TAVI previous E PJ T DH Harrison S of prevalence and risk factors for after transcatheter aortic valve implantation.Am J Cardiol. 2018; PubMed Scopus Google Scholar were also assessed in the study and were not associated with post-TAVI cognitive Additionally, E PJ T DH Harrison S of prevalence and risk factors for after transcatheter aortic valve implantation.Am J Cardiol. 2018; PubMed Scopus Google Scholar pre-TAVI cognitive impairment as a risk for in the study baseline cognitive impairment was associated with cognitive improvement. further is to predictive factors for cognitive decline and after TAVI. be due to sample and the assessment of subgroups this meta-analysis was the first to literature and report the prevalence of cognitive decline and improvement after TAVI, was not 15 studies in sample within analyses. to large heterogeneity was in prevalence at all time-points which included both relaxed and robust definitions of cognitive by these definitions increased The change which for and has shown to well in change associated with a change in A comparison of methods for cognitive change in PubMed Scopus Google Scholar We studies a change for significant cognitive change, as individual change in comparison to the not the of risk factors reported in included studies a analysis of of cognitive change after TAVI to be is in this which of cognitive change post-TAVI (e.g., and transapical TAVI has as the in the of symptomatic aortic stenosis for for the surgical the review that cognitive an post-TAVI is as an as cognitive improvement from 7% to The also that most approximately to not any long-term cognitive change post-TAVI. Assessment of these subgroups will a approach in TAVI, the and of in at risk of cognitive The that they have no or that have to the reported in this The report no that be as a of The the of with

Topics & Concepts