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Title: Carotid disease, neurocognitive function, and frailty in patients undergoing transcatheter aortic valve intervention
Author: Michel, Jonathan Marc
ISNI:       0000 0004 8502 9004
Awarding Body: St George's, University of London
Current Institution: St George's, University of London
Date of Award: 2019
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In this thesis, I have explored the effect of latent baseline clinical factors on outcomes after transcatheter aortic valve implantation (TAVI). The first project explores the impact of carotid stenosis at the time of TAVI on the risk of 30-day stroke. A total of 616 patients were divided into four groups based on pre-operative carotid duplex findings. The prevalence of carotid stenosis >49% was 14%. In multivariate analysis, unilateral carotid occlusion was associated with significantly higher odds of 30-day stroke (OR 8.58 [95% C.l. 2-35], p = 0.003). In the second project, 284 patients underwent prospective baseline neurocognitive testing before TAVI with the Montreal Cognitive Assessment (MoCA). Overall, 82% patients had an abnormal baseline MoCA test (score <26). In patients returning to clinic, there was no significant difference in MoCA score before and after TAVI and no clinically significant differences between patients with and without a >2 point reduction in score. The high rate of abnormal baseline testing may limit the utility of the MoCA. In project three, 1731 TAVI patients underwent retrospective CT frailty evaluation by means of psoas muscle cross-sectional area (CSA) and the association with subsequent mortality. The lowest psoas CSA quartile had the highest mortality, and unadjusted survival was significantly different in males (log rank p = 0.041) but not females (p = 0.099). Psoas CSA was not significantly associated with mortality after adjusting for preprocedural variables. Project four investigated the utility of the Edmonton Frail Scale (EFS) to predict 30-day morbidity after TAVI: 289 patients were included. The morbidity endpoint occurred in 18% and was significantly more likely in the high frailty (EFS >10) group (38% versus EFS 6-9 [14%] and EFS <6 [17%]; p = <0.05); however, statistical significance did not persist after multivariable adjustment.
Supervisor: Not available Sponsor: Not available
Qualification Name: Thesis (M.D.) Qualification Level: Doctoral
EThOS ID:  DOI: Not available