Mild Cognitive Decline 2-6 Months After Heart Valve Surgery Interview with

Mark Oldham, M.D. Assistant Professor of Psychiatry Medical Director, PRIME Medicine Proactive Integration of Mental Health Care in Medicine University of Rochester Medical Center

Dr. Oldham

Mark Oldham, M.D.
Assistant Professor of Psychiatry
Medical Director, PRIME Medicine
Proactive Integration of Mental Health Care in Medicine
University of Rochester Medical Center What is the background for this study?

Response: Patients who have undergone coronary artery bypass graft (CABG) surgery and, specifically, those who have been placed on cardiopulmonary bypass (CPB) have received attention for the potential effects of such procedures on brain health. Heart valve surgery patients have received far less attention, which often leaves clinicians to extrapolate the data from CABG cohorts to their patients preparing to undergo valve surgery. However, there are many reasons why this is far less than ideal, especially as the CABG literature increasingly points to person- and procedure-specific factors as the determinants of postoperative cognitive outcomes. What are the main findings?

Response: Our meta-analysis found that heart valve surgery subjects assessed preoperatively and up to 1 month post-surgery experience, on average, moderate cognitive decline (Becker mean gain effect size -0.39). Similarly, heart valve surgery subjects were found, on average, to have mild cognitive decline relative to preoperative cognitive baseline when assessed from 2-6 months post-surgery (Becker -0.25). Stratifying studies by heart valve (i.e., aortic, mitral, or mixed cohorts undergoing aortic or mitral valve surgery) revealed that aortic valve subjects were older than mitral valve subjects by roughly a decade (68 vs 57). Aortic valve subjects had greater cognitive decline than mitral valve subjects, but both cohorts had similar, mild decline 2-6 months post-surgery. What should readers take away from your report?

Response: The heart valve surgery population is often overlooked for their unique cognitive vulnerability. Additional research is needed to disentangle the person- and procedure-specific factors that contribute to cognitive decline. Further, given that aortic valve surgery subjects were roughly a decade older than mitral valve subjects, additional study is needed to differentiate the potential effects of aortic surgery, older age (which often itself attests to cognitive vulnerability), some potential interaction between these factors, as well as additional factors. Finally, longer-term studies are needed to understand cognitive outcomes beyond 6 months post-surgery. What recommendations do you have for future research as a result of this work? 

Response: Future studies centered on valve heart surgeries would do well to enroll increasingly homogeneous populations and standardize surgical procedures as much as feasible. It remains to be seen whether person-specific factors, especially those among older adults undergoing aortic valve surgery, may prove to be more robust predictors of cognitive outcomes than the specific surgery itself. Finally, the indications for transcatheter aortic valve replacement (TAVR) continue to expand. We await studies that offer insight into the differential effects of TAVR and surgical aortic valve surgery on cognitive and functional outcomes. For instance, subjects with similar surgical risk who chose one procedure over the other might be matched based on propensity score for cognitive decline based on a range of known cognitive predictors.

We have no conflicts of interest to disclose. 


Oldham, M. A., Vachon, J. , Yuh, D. and Lee, H. B. (2018), Cognitive Outcomes After Heart Valve Surgery: A Systematic Review and Meta‐Analysis. J Am Geriatr Soc. . doi:10.1111/jgs.15601 

Oct 17, 2018 @ 10:52 pm

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