Cognition and Cerebral Infarction in Older Adults After Surgical Aortic Valve Replacement

Giovannetti, Tania; Price, Catherine C.; Fanning, Molly; Messé, Steven R.; Ratcliffe, Sarah J.; Lyon, Abigail C.; Kasner, Scott E.; Seidel, Gregory; Bavaria, Joseph E.; Szeto, Wilson Y.; Hargrove, W. Clarke; Acker, Michael A.; Floyd, Thomas F.

doi:10.1016/j.athoracsur.2018.09.057

Cited by 25 publications

(19 citation statements)

References 39 publications

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“…Santarpino and Moscarelli [1] noted our high attrition rate, which was significantly higher and associated with death and stroke in the surgical group. Although we acknowledge that surgical participants who did not complete the study might have experienced cognitive decline, another perspective is that outcomes would have been worse for even more of these medically complex participants if they did not undergo surgery.…”

Section: Replymentioning

confidence: 72%

“…We thank Santarpino and Moscarelli [1] for their comments on our article [2]. Our interdisciplinary team [2] followed a large cohort of older individuals who underwent surgical aortic valve replacement for aortic stenosis (n ¼ 190) in a prospective, longitudinal study that included a nonsurgical comparison group with similar, though less severe, cardiovascular disease (n ¼ 198).…”

Section: Replymentioning

confidence: 99%

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Postoperative Cognitive Dysfunction: A Forgotten Part of the Quality of Life?

Santarpino

Moscarelli

2019

The Annals of Thoracic Surgery

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The increased average age of patients undergoing cardiac surgery has raised concerns about the possible onset of postoperative cognitive dysfunction (POCD). This issue is of particular relevance because older patients more frequently undergo cardiac surgery for improving rather than quantitating quality of life. Moreover, the achievement of a better quality of life can preserve psychic function and provide greater independence in performing activities of daily living, which is of greater importance in these patients than being able to handle physical challenges. The occurrence of POCD, therefore, represents a serious failure of the aforementioned surgical goals.In this regard, we read with interest the article by Giovannetti and colleagues [1], who analyzed older patients undergoing surgical aortic valve replacement with clinical and radiologic tests. The authors conclude that the incidence of POCD was surprisingly low. In their opinion, advanced age does not represent per se a risk for POCD. Because we have entered the transcatheter aortic valve implantation (TAVI) era, older patients with aortic valve stenosis have been topic of debate, and the potential for POCD necessarily stimulates comments on this matter.In the study, patients undergoing surgery had better outcomes than those of the control group, although patients who underwent operations were significantly older, more depressed, exhibited increased morbidity, and had a worse mini-mental test result at the margin of statistical significance. The authors, however, also reported that among surgery participants who did not complete clinical and radiologic evaluation, 35% died. In other words, in-hospital mortality was approximately 7%. It would have been interesting if more information was given regarding POCD, cerebral risks, and inhospital and operative data that might have influenced the deaths. Patients who were excluded from the analysis had significantly more strokes. In our opinion, this aspect should have been emphasized to avoid misinterpretation of the takehome message.Notwithstanding, patients with severe aortic stenosis must be treated. But what about POCD risk if they had undergone TAVI? This question remains largely unanswered, as there is little information regarding the risk of POCD associated with TAVI, ranging from studies reporting no cognitive impairment to those in which 1 of 3 patients developed neurologic complications.The German TAVI Registry suggests that the risk for cerebral events in patients undergoing TAVI is low (approximately 3%), but a more comprehensive evaluation is needed, comparing TAVI versus surgery in terms of POCD. This topic has a strong influence on the quality of life of these older patients.

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Section: Replymentioning

confidence: 72%

Section: Replymentioning

confidence: 99%

Postoperative Cognitive Dysfunction: A Forgotten Part of the Quality of Life?

Santarpino

Moscarelli

2019

The Annals of Thoracic Surgery

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“…Moreover, as a result of extensive nature of POCD development, and to track earlier diagnosed cognitive impairment, another late cognitive evaluation is obligatory, likely at twelve months following surgery 11,12 . However, late cognitive assessments are particularly questionable, given that late cognitive deterioration may be just repercussion of the progression of cardiovascular or cerebrovascular diseases, natural aging, or dementia 13 .…”

Section: Discussionmentioning

confidence: 99%

“…At last, different statistical methods have been commonly utilized to define POCD, however, each representing a two-sided coin 12 . A reliable change index seems to be most suitable for POCD research, as it overcomes learning effect, however, this method advocates the inclusion of a control group, which can be very tricky 13 . Specifically, the absence of physiological processes induced by cardiopulmonary bypass and cardiac surgery itself in patients included in a control group represents a significant bias that cannot be overpowered.…”

Section: Discussionmentioning

confidence: 99%

“…A simple search of the PubMed database using two medical subject heading (MeSH) terms, i.e., cardiac surgical procedures and cognitive dysfunction, revealed 410 related publications, indicating the high level of attention that different experts have dedicated to this interesting topic. Perhaps the most valid reason why the expected breakthrough in clarifying this clinically important query has been lacking over time lies in inconsistent methodology that has been used in POCD studies 3,13 . Therefore, similarly designed studies very often provide contradictory results, significantly complicated conclusions, and fail to set proper directions for future research 12 .…”

Section: Methodological Inconsistencymentioning

confidence: 99%

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Is It Time to Redefine Cognitive Dysfunction after Cardiac Surgery? The Importance of Methodological Consistency

Glumac¹,

Kardum²,

Karanović³

2021

ACC

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High incidence and significance of repercussions on patient health and healthcare system make postoperative cognitive dysfunction (POCD) a major problem following cardiac surgery. POCD frequency drops over time since surgery and its occurrence are related to different aspects of cognitive deterioration that markedly impair the patient quality of life. Therefore, a substantial number of papers have focused on this complex postoperative complication, however, with limited achievement in clarifying it. The underlying mechanisms of POCD development and contributing factors are still unclear. A significant issue in POCD research is the lack of uniformity in defining cognitive impairment among investigators, including unique terminology of cognitive changes, a battery of appropriate neuropsychological tests, timing of assessment, and statistical approach. Thus, the aim of this review is to address the difficulties in establishing POCD definition, with inclusion of specific recommendations based on recent publications.

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