Modifications in ocular microperfusion after transcatheter aortic valve implantation

Abstract

Cerebral embolization is a known complication of transcatheter aortic valve implantation (TAVI) but the effect of the procedure on the ocular perfusion is currently unclear. Thus, we investigated post-procedural morphologic and perfusion changes of the retina and choroid, using optical coherence tomography angiography (OCTA) and color fundus photography (CFP) in a prospective cohort study. Ophthalmic examinations were conducted pre- and post-TAVI. OCTA images were analyzed quantitatively based on vessel density and skeleton density of the superficial and deep retinal plexus as well as the signal intensity and flow deficits in the choriocapillaris. CFP images were assessed for presence of acute retinal ischemia, optic nerve swelling, vessel emboli, hemorrhages and cotton wool spots. Data was analyzed using linear mixed models. Twenty patients (9 women; 11 men) at a mean age of 81 ± 6 years were included. Pre- and post-interventional ocular imaging data were available for 32 eyes. The analysis revealed a significant impairment of the choriocapillaris perfusion after TAVI with an increased proportion of flow deficits (p = 0.044). When controlling for blood pressure, the average size of choriocapillaris flow voids was significantly increased (systolic and diastolic, p = 0.039 and 0.029). Qualitatively, focal areas of retinal ischemia were detected on OCTA in 33% of participants. Silent emboli or cotton wool spots were identified on CFP in 21%. Our findings indicate a reduced choroidal perfusion as well as areas of retinal ischemia and embolization in a considerable proportion of patients following TAVI. Pending confirmation in a larger sample, these complications merit monitoring as well as inclusion in consent procedures for TAVI.

Figure 1

Perfusion of the retinal and choriocapillaris microvasculature pre- and post- transcatheter aortic valve implantation (TAVI), measured by optical coherence tomography angiography of the macula. Values over 1.5 interquartile range below the first quartile or above the third quartile were defined as outliers. The displayed data include data from both eyes.

Figure 2

Imaging modalities implemented in the study in an exemplary participant: Color fundus photography (a), and optical coherence tomography angiography (b–e); superficial retinal plexus, deep retinal plexus and choriocapillaris en face projections), pre-TAVI (a–d) and post-TAVI (e). Choriocapillaris flow deficits are focal, dark areas in panels d and e.