Anemia and risk of periprocedural cerebral injury detected by diffusion-weighted magnetic resonance imaging in patients undergoing transcatheter aortic valve replacement

doi:10.5847/wjem.j.1920-8642.2022.025

Abstract

Abstract:

BACKGROUND: Anemia is prevalent in patients undergoing transcatheter aortic valve replacement (TAVR) and has been linked to impaired outcomes after the procedure. Few studies have evaluated the impact of anemia and new ischemic lesions post TAVR.
METHODS: We prospectively enrolled 158 patients who received TAVR in our center. Anemia was defined according to the World Health Organization criteria as hemoglobin <12 g/dL in women and <13 g/dL in men. All patients underwent diffusion-weighted magnetic resonance imaging (DW-MRI) procedure before and within 4-7 days after TAVR.
RESULTS: Anemia was present in 85 (53.8%) patients who underwent TAVR, and 126 (79.7%) patients had 718 new DW-MRI positive lesions with a mean of 4.54±5.26 lesions per patient. The incidence of new ischemic lesions was 81.2% in patients with anemia versus 78.1% in patients without anemia (P=0.629). Moreover, anemic patients had bigger total volume/lesions in the anterior cerebral artery/middle cerebral artery (ACA/MCA) and MCA regions compared to the non-anemic patients (31.89±55.78 mm ³ vs. 17.08±37.39 mm³, P=0.049; and 54.54±74.72 mm ³ vs. 33.75±46.03 mm³, P=0.034). Anemia was independently associated with the volume/lesion in the ACA/MCA (β=16.796, 95% confidence interval [95% CI] 2.001 to 31.591, P=0.026) and in the MCA zone (β=0.020, 95% CI 0.001 to 0.040, P=0.041).
CONCLUSIONS: Patients with pre-procedural anemia may have bigger total volume/lesions in the ACA/MCA and MCA regions compared to the non-anemic patients. Whether the consequences of bigger total volume/lesions impact neurological and cognitive outcomes remains to be investigated.

Key words: Aortic stenosis, Anemia, Cerebral ischemic lesions, Transcatheter aortic valve replacement

Stella Ng, Qi-feng Zhu, Ju-bo Jiang, Chun-hui Liu, Jia-qi Fan, Ye-ming Xu, Xian-bao Liu, Jian-an Wang. Anemia and risk of periprocedural cerebral injury detected by diffusion-weighted magnetic resonance imaging in patients undergoing transcatheter aortic valve replacement[J]. World Journal of Emergency Medicine, 2022, 13(1): 32-39.

Figures/Tables 5

Figure 1.

Table 1

Baseline characteristics of anemic and non-anemic TAVR patients

Variables	All patients (n=158)	Anemic patients (n=85)	Non-anemic patients (n=73)	P-value
Age, years	78±7	80±6	76±6	<0.001
Male	94 (59.5)	53 (62.4)	41 (56.2)	0.430
Body Mass Index, kg/m²	22.38±3.39	21.55±3.47	23.35±3.04	0.001
NYHA class III/IV	143 (90.5)	77 (90.6)	66 (90.4)	0.321
STS score	7.17±4.35	8.77±4.73	5.32±2.94	<0.001
Past history
Smoker	27 (17.1)	10 (11.8)	17 (23.3)	0.055
Dyslipidemia	18 (11.4)	11 (12.9)	7 (9.6)	0.508
Diabetes mellitus	40 (25.3)	27 (31.8)	13 (17.8)	0.113
Hypertension	85 (53.8)	46 (54.1)	39 (53.4)	0.931
Peripheral vascular disease	13 (8.2)	10 (11.8)	3 (4.1)	0.081
Atrial fibrillation	26 (16.5)	12 (14.1)	14 (19.2)	0.392
COPD	40 (25.3)	22 (25.9)	18 (24.7)	0.860
Prior PCI	14 (8.9)	11 (12.9)	3 (4.1)	0.051
Prior CABG	0 (0)	0 (0)	0 (0)	-
Prior myocardial infarction	2 (1.3)	1 (1.2)	1 (1.4)	0.914
Prior PPI	0 (0)	0 (0)	0 (0)	-
Prior stroke	11 (7.0)	6 (7.1)	5 (6.8)	0.959
Syncope	16 (10.1)	5 (5.9)	11 (15.1)	0.056
Medication on admission				0.370
Antiplatelet	84 (53.2)	48 (56.5)	36 (49.3)
Anticoagulation	18 (11.4)	7 (8.2)	11 (15.1)
No antithrombosis	56 (35.4)	30 (35.3)	26 (35.6)
Laboratory data on admission
Hemoglobin, g/dL	12.2±1.6	11.2±1.3	13.4±0.9	<0.001
INR	1.12±0.36	1.12±0.34	1.12±0.38	0.994
APTT, s	38.2±5.7	38.6±6.6	37.9±4.6	0.436
NT-proBNP, pg/mL	2,119 (669-5,623)	3,101 (1,162-8,124)	1,075 (428-2,562)	0.015
Creatinine, μmol/L	84.66±31.63	90.81±37.70	77.49±20.66	0.006
eGFR, mL/(min·1.73m²)	54.49±20.58	48.56±18.58	61.39±20.77	<0.001
Echocardiography
LVEF, %	54.91±14.88	52.78±15.42	57.40±13.91	0.052
Mean gradient, mmHg	58.70±34.94	57.92±19.52	59.60±47.07	0.764
Maximum velocity, m/s	4.83±0.82	4.91±0.79	4.73±0.85	0.187
Aortic valve area, cm²	0.56±0.23	0.55±0.20	0.57±0.26	0.551
Carotid stenosis (II+)	6 (3.8)	5 (5.9)	1 (1.4)	0.218

Table 1

Table 2

Table 3

Post-procedural DW-MRI findings

Variables	All patients (n=158)	Anemic patients (n=85)	Non-anemic patients (n=73)	P-value
Time of post-procedural MRI, days	5 (4-7)	5 (4-7)	5 (4-6)	0.195
Patients with new lesions	126 (79.7)	69 (81.2)	57 (78.1)	0.629
Lesion location (patients)				0.107
Left hemisphere lesions	20 (15.9)	11 (15.9)	9 (15.8)
Right hemisphere lesions	22 (17.5)	7 (10.1)	15 (26.3)
Bihemispheric lesions	84 (66.7)	51 (73.9)	33 (57.9)
Total number of lesions	718	379	339
Number of lesions per patient	4.54±5.26	4.46±4.73	4.64±5.84	0.826
ACA lesions (n=97)	0.61±1.13	0.58±1.02	0.66±1.25	0.654
Total volume ACA lesions, mm³	45.13±102.68	38.59±77.02	52.74±126.33	0.389
Total volume/lesions in ACA, mm³	24.75±51.58	24.71±52.41	24.79±50.97	0.991
ACA/MCA lesions* (n=98)	0.62±1.25	0.73±1.25	0.49±1.26	0.239
Total volume ACA/MCA lesions, mm³	50.06±112.45	63.06±126.90	34.93±91.40	0.109
Total volume/lesions in ACA/MCA, mm³	25.05±48.59	31.89±55.78	17.08±37.39	0.049
MCA lesions (n=218)	1.38±2.12	1.51±2.07	1.23±2.18	0.422
Total volume MCA lesions, mm³	124.43±246.70	147.41±262.18	97.67±226.20	0.207
Total volume/lesions in MCA, mm³	44.93±63.78	54.54±74.72	33.75±46.03	0.034
MCA/PCA lesions* (n=20)	0.13±0.49	0.12±0.52	0.14±0.45	0.805
Total volume MCA/PCA lesions, mm³	8.54±34.06	8.35±35.52	8.77±32.53	0.940
Total volume/lesions in MCA/PCA, mm³	6.00±23.97	5.91±26.75	6.10±20.45	0.962
PCA lesions (n=143)	0.90±1.72	0.69±1.53	1.14±1.90	0.112
Total volume PCA lesions, mm³	175.00±1,232.21	70.71±262.21	296.44±1,789.64	0.252
Total volume/lesions in PCA, mm³	43.42±160.58	28.43±53.78	60.87±228.65	0.207
VA/BA lesions* (n=143)	0.91±1.45	0.84±1.49	0.99±1.42	0.517
Total volume VA/BA lesions, mm³	180.70±638.99	164.00±600.66	200.14±684.61	0.724
Total volume/lesions in VA/BA, mm³	104.48±468.14	110.46±558.37	97.51±337.72	0.863

Table 3

Table 4

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Variables	All patients (n=158)	Anemic patients (n=85)	Non-anemic patients (n=73)	P-value
Procedural data
Valve type				0.768
Self-expanding	126 (79.7)	68 (80.0)	58 (79.5)
Balloon-expandable	29 (18.4)	16 (18.8)	13 (17.8)
Mechanically-expandable	3 (1.9)	1 (1.2)	2 (2.7)
Pre-dilatation	152 (96.2)	83 (97.6)	69 (94.5)	0.416
Post-dilatation	79 (50.0)	40 (47.1)	39 (53.4)	0.425
Duration of procedure, minutes	64.41±32.67	64.60±30.49	64.19±35.26	0.938
Mortality
In-hospital	0 (0)	0 (0)	0 (0)	-
30-day	0 (0)	0 (0)	0 (0)	-
1-year	5 (3.2)	4 (4.7)	1 (1.4)	0.374
Length of stay, days	7 (7-9)	8 (4-12)	7 (5-9)	<0.001
Myocardial infarction	0 (0)	0 (0)	0 (0)	-
Stroke	5 (3.2)	4 (4.7)	1 (1.4)	0.374
Disabling stroke	0 (0)	0 (0)	0 (0)	-
Non-disabling stroke	5 (3.2)	4 (4.7)	1 (1.4)	0.374
Bleeding	39 (24.7)	21 (24.7)	18 (24.7)	0.994
Blood transfusion	12 (7.6)	10 (11.8)	2 (2.7)	0.033
Acute kidney injury	3 (1.9)	2 (2.4)	1 (1.4)	1.000
Vascular complication	17 (10.8)	10 (11.8)	7 (9.6)	0.660
New atrial fibrillation	6 (3.8)	3 (3.5)	3 (4.1)	1.000
New LBBB	21 (13.3)	11 (12.9)	10 (13.7)	0.889
New atrioventricular block	20 (12.7)	11 (12.9)	9 (12.3)	0.908
New pacemaker implantation	3 (1.9)	1 (1.2)	2 (2.7)	0.596
Pre-discharge hemoglobin, g/dL	10.5±1.9	9.6±1.7	11.6±1.5	<0.001

Variables	ACA/MCA region						MCA region
	Univariate		Multivariate				Univariate		Multivariate
	R	P-value	β	t	P-value	95% CI	R	P-value	β	t	P-value	95% CI
Age	0.007	0.930					0.025	0.757
Male	0.019	0.813					0.045	0.575
NYHA class	0.195	0.014	-14.361	-2.716	0.007	-24.807 to -3.915	0.106	0.186
STS score	0.027	0.736					0.034	0.674
Medication on admission	0.041	0.610					0.068	0.394
Past history
Smoker	0.111	0.166					0.092	0.252
Diabetes mellitus	0.016	0.844					0.069	0.388
Hypertension	0.004	0.960					0.037	0.642
Dyslipidemia	0.121	0.130					0.061	0.443
Prior myocardial infarction	0.059	0.465					0.027	0.740
Prior PCI	0.036	0.649					0.102	0.203
Prior stroke	0.046	0.566					0.027	0.735
Peripheral vascular disease	0.008	0.923					0.066	0.408
Atrial fibrillation	0.119	0.135					0.059	0.458
Anemia	0.152	0.056	16.796	2.243	0.026	2.001 to 31.591	0.163	0.041	0.020	2.039	0.041	0.001 to 0.040
Laboratory data
Hemoglobin	0.095	0.237					0.059	0.460
INR	0.103	0.196					0.069	0.390
APTT	0.108	0.175					0.109	0.174
Pre-TAVR echocardiography
Mean gradient	0.152	0.056	0.218	2.043	0.043	0.007 to 0.430	0.009	0.910
Aortic valve area	0.038	0.640					0.059	0.458
Maximum velocity	0.179	0.025					0.052	0.519
Carotid stenosis (II+)	0.093	0.243					0.025	0.751
Procedural data
Valve types	0.097	0.224					0.197	0.013	-0.025	-2.316	0.022	-0.046 to -0.004
Pre-dilatation	0.011	0.887					0.036	0.651
Post-dilatation	0.075	0.348					0.074	0.355
Procedural time	0.137	0.086					0.139	0.082

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