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ObjectiveTo compare the incidence of silent cerebral infarction and impact on cognitive function following transcatheter aortic valve implantation (TAVI) with the first-generation CoreValve (Medtronic, Minneapolis, Minnesota, USA) and second-generation Lotus valve (Boston Scientific, Natick Massachusetts, USA).DesignA prospective observational study comprising a 1.5 T cerebral MRI scan, performed preoperatively and immediately following TAVI, and neurocognitive assessments performed at baseline, 30 days and 1 year follow-up.SettingUniversity hospitals of Leeds and Leicester, UK.Patients66 (80.6±8.0 years, 47% male) patients with high-risk severe symptomatic aortic stenosis recruited between April 2012 and May 2015.Main outcome measuresIncidence of new cerebral microinfarction and objective decline in neurocognitive performance.ResultsAll underwent cerebral MRI at baseline and immediately following TAVI, and 49 (25 Lotus, 24 CoreValve) completed neurocognitive assessments at baseline, 30 days and 1 year. There was a significantly greater incidence of new cerebral microinfarction observed following the Lotus TAVI (23 (79%) vs 22 (59%), p=0.025) with a greater number of new infarcts per patient (median 3.5 (IQR 7.0) vs 2.0 (IQR 3.0), p=0.002). The mean volume of infarcted cerebral tissue per patient was equivalent following the two prostheses (p=0.166). More patients suffered new anterior (14 (48%) vs 2 (5%), p=0.001) and vertebrobasilar (15 (52%) vs 7 (19%), p=0.005) lesions following Lotus. Lotus was associated with a decline in verbal memory and psychomotor speed at 30 days. However, performance longitudinally at 1 year was preserved in all neurocognitive domains.ConclusionsThere was a higher incidence of silent cerebral microinfarction and a greater number of lesions per patient following Lotus compared with CoreValve. However, there was no objective decline in neurocognitive function discernible at 1 year following TAVI with either prosthesis.

Background— Incidence of cerebral microinfarcts is higher after transcatheter aortic valve implantation (TAVI) compared with surgical aortic valve replacement (SAVR). It is unknown whether these lesions persist and what direct impact they have on health-related quality of life. The objective was to identify predictors of cerebral microinfarction and measure their effect on health-related quality of life during 6 months after TAVI when compared with SAVR. Methods and Results— Cerebral MRI was conducted at baseline, post procedure, and 6 months using diffusion-weighted imaging. Health-related quality of life was measured at baseline, 30 days, and 6 months with short form-12 health outcomes and EuroQol 5 dimensions questionnaires. One hundred eleven patients (TAVI, n=71; SAVR, n=40) were studied. The incidence (54 [77%] versus 17 [43%]; P =0.001) and number (3.4±4.9 versus 1.2±1.8; P =0.001) of new microinfarcts were greater after TAVI than after SAVR. The total volume per microinfarct was smaller in TAVI than in SAVR (0.23±0.24 versus 0.76±1.8 mL; P =0.04). The strongest associations for microinfarction were: TAVI (arch atheroma grade: r =0.46; P =0.0001) and SAVR (concomitant coronary artery bypass grafting: r =−0.33; P =0.03). Physical component score in TAVI increased after 30 days (32.1±6.6 versus 38.9±7.0; P P P Conclusions— Cerebral microinfarctions are more common after TAVI compared with SAVR but seem to have no negative effect on early (30 days) or medium term (6 months) health-related quality of life. Aortic atheroma (TAVI) and concomitant coronary artery bypass grafting (SAVR) are independent risk factors for cerebral microinfarction.

Background Transcatheter Aortic Valve Implantation (TAVI) is used to treat symptomatic severe aortic stenosis in a non-surgical high risk population. The incidence of stroke and micro-infarction is higher in the TAVI population compared to surgical aortic valve replacement (SAVR) at 30 days, which may be due to various factors such as valve calcification and aortic atheroma. However, the natural history and clinical consequences of micro-infarction is unknown.

'Silent' cerebral infarction and stroke are complications of transcatheter aortic valve implantation (TAVI).To assess the occurrence of cerebral infarction, identify predictive risk factors and examine the impact on patient health-related quality of life (HRQoL).Cerebral diffusion weighted MRI of 31 patients with aortic stenosis undergoing CoreValve TAVI was carried out. HRQoL was assessed at baseline and at 30 days by SF-12v2 and EQ5D questionnaires.New cerebral infarcts occurred in 24/31 patients (77%) and stroke in 2 (6%). Stroke was associated with a greater number and volume of cerebral infarcts. Age (r=0.37, p=0.042), severity of atheroma (arch and descending aorta; r=0.91, p0.001, r=0.69, p=0.001, respectively) and catheterisation time (r=0.45, p=0.02) were predictors of the number of new cerebral infarcts. HRQoL improved overall: SF-12v2 physical component summary increased significantly (32.4±6.2 vs 36.5±7.2; p=0.03) with no significant change in mental component summary (43.5±11.7 vs. 43.1±14.3; p=0.85). The EQ5D score and Visual Analogue Scale showed no significant change (0.56±0.26 vs. 0.59±0.31; p=0.70, and 54.2±19 vs. 58.2±24; p=0.43).Multiple small cerebral infarcts occurred in 77% of patients with TAVI. The majority of infarcts were 'silent' with clinical stroke being associated with a both higher infarct number and volume. Increased age and the severity of aortic arch atheroma were independent risk factors for the development of new cerebral infarcts. Overall HRQoL improved and there was no association between the number of new cerebral infarcts and altered health status.

Subarachnoid haemorrhage remains a major cause of morbidity and mortality throughout the world. Of those suffering the condition, 15% are known to die before they reach hospital and half of all patients die within 1 month of presentation. Of those patients who survive the initial 30 days, just under half are believed to remain dependent for their normal activities of daily living. In the vast majority of cases, SAH results from the rupture of an intracranial aneurysm. After patient stabilisation, primary treatment is focused on the prevention of re-bleeding. Until recently, this exclusively involved the surgical clipping of the ruptured aneurysm via a craniotomy. The early 1990s, with the introduction of aneurysmal coiling via endovascular intervention, heralded the dawn of a new treatment option. Presently, endovascular therapy largely supersedes surgical intervention in the management of intracranial aneurysms in the developed world. Moreover, with the emergence of new technologies and approaches for the treatment of aneurysms, the field of neurovascular intervention is only likely to expand further. However, due to its relative infancy, unanswered questions regarding long term endovascular outcome remain. This is particularly pertinent to newer techniques of embolisation for which data on complete aneurysmal occlusion rates are limited. Thus, to understand fully the capability and limitations of this treatment, further well constructed randomised controlled trials are a necessity.