Identification of Epigenetic Risk Factors for Ischemic Complication During the TAVR Procedure in the Elderly

Study Overview
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Brief Summary
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Over the past ten years, the number of endovascular procedures has increased by 5% per year in Europe with the development of interventional cardiology, such as percutaneous coronary angioplasty, aortic valve replacements (TAVR), and vascular endoprosthesis. The neurological lesions detected on cerebral MRI caused by these endovascular procedures are frequent with an incidence of about 30-70%. These events, although subclinical, have an impact on morbidity and mortality and especially on long-term cognitive decline. TAVR is the reference treatment for symptomatic elderly patients with stenosis of the aortic valve, considered by a multidisciplinary Heart Team as at high surgical risk due to comorbidities, age and high perioperative risk scores ( Euroscore 2 and STS scores). Despite the net clinical benefit, an increase of silent neurological events was detected on post-procedural cerebral MRI with an incidence of approximately 70%. The epigenetic involvement in the occurrence of ischemic cerebral lesions is still largely unknown. Epigenetic mechanisms, such as DNA methylation, can be associated with aging processes and modulate the risk of developing cerebrovascular pathologies. They are likely to provide new biomarkers that predict the risk of brain damage. Hypomethylation of leukocyte DNA is directly related to atherosclerosis in humans. This hypomethylation of DNA would represent an easily measurable marker reflecting the presence and progression of atherosclerosis. Because atherosclerotic lesions often precede the clinical manifestation of ischemic cardiovascular disease, such as ischemic heart disease and stroke, DNA hypomethylation could be used to identify individuals at risk for cerebrovascular events. The investigator hypothesize that hypomethylation of leukocyte DNA can predict the risk of developing new ischemic brain lesions especially after a TAVI procedure.

Detailed Description
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This is a french multicenter prospective cohort study. Patients with severe symptomatic aortic stenosis referred for a TAVI procedure to the cardiology departments of the university hospitals of Lille, Caen, Amiens and the Pitié-Salpêtrière hospital (APHP) are analyzed for inclusion in this prospective study. The cases are selected after a discussion between the members of the local TAVI Heart Team (cardiologists, cardiac surgeons, anesthetists), as recommended by the guidelines of the European Society of Cardiology. Written consent is obtained in accordance with international recommendations for clinical research (Helsinki Declaration). Participation in the study is proposed to patients during preoperative consultation. The collection of clinical data, including postoperative cerebral MRI, is collected prospectively during hospitalization and during the clinical visit to each institution at one year. An evaluation of cognitive function is performed by a mini-mental state (MMS) the day before the TAVI intervention and then at 1 year. The study ends after the last evaluation. A cerebral MRI is performed within 1-3 days after the TAVI procedure to detect new cerebral ischemic lesions (emboli). Blood samples will be taken during the patient's stay: the day before TAVI, during the procedure and after the TAVI procedure at day 1 and day 4. The follow-up visit to 1 year will be conducted by cardiologists or cardiac surgeons with an evaluation of the cognitive function by the mini-mental state (MMS).

Official Title
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Identification of Epigenetic Risk Factors for Ischemic Complication During the TAVR Procedure in the Elderly

Conditions
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Cognitive Decline, Stroke

Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Patients over 70 years with severe aortic stenosis requiring percutaneous aortic valve replacement (TAVI) Exclusion Criteria: Patient contraindicated for the TAVI procedure Patient with a pace-maker Patient with contra-indication for cerebral MRI Ongoing cancer Patient already involved in therapeutic research Major persons under protection of justice.

Ages Eligible for Study
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Minimum Age: 70 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Cerebral Lesion<br>Patient over 70 years with severe aortic stenosis requiring percutaneous aortic valvular replacement (TAVI) having at least one new cerebral ischemic lesion on postoperative cerebral MRI | |
| No Cerebral Lesion<br>Patient over 70 years with severe aortic stenosis requiring percutaneous aortic valvular replacement (TAVI) with no cerebral ischemic lesion on postoperative cerebral MRI | |
| patients with constitutional von Willebrand factor (vWF) deficiency<br> | |

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Pre-operative leukocyte DNA methylation rate | This rate will be measured by the LUMA method in patients treated with TAVI according to the presence of at least one new cerebral ischemic lesion and/or microbleeds cerebral lesion appearing on post-procedural MRI | Within one week after the procedure | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Variation of the leukocyte DNA methylation rate during the TAVI procedure | This rate will be measured by the LINE-1 method in all patients | At time between the pre (day-1) and postprocedural (day 1) samples | 
| Pre-operative leukocyte DNA methylation rate (stroke/TIA) | This rate will be measured by the LUMA method in patients treated with TAVI according to the presence of a neurological deficit (stroke, transient ischemic attack) | One day before the procedure and within one week after the procedure | 
| Mortality | The mortality in patients treated with TAVI according to the presence of at least one new micro-ischemic cerebral lesion and/or one new microbleeds cerebral lesion detected on postoperative cerebral MRI and / or postprocedural ischemic stroke / TIA | At 1 year after procedure | 
| MMSE score variation | The MMSE score variation is compared according to the presence or not of at least one new micro-ischemic cerebral lesion and/or one new microbleeds cerebral lesion | At day-1 before TAVI procedure, at 6 months and at 1 year after procedure | 
| Change of EQ-5D questionnaire | The evolution of quality of life is compared to the occurrence of new cerebral events one new micro-ischemic cerebral lesion and/or one new microbleeds cerebral lesion | At day-1 before TAVI procedure, at 6 months and at 1 year after procedure | 
| Change of modified Rankin Scale (mRS) | The MRS (measure degree of disability- troke) is compared to the occurrence of new cerebral events one new micro-ischemic cerebral lesion and/or one new microbleeds cerebral lesion | At day-1 before TAVI procedure, at 6 months and at 1 year after procedure | 
| Change of National Institutes of Health Stroke Scale (NIHSS) | TheNIHSS (quantify the impairment caused by a stroke) is compared to the occurrence of new cerebral events one new micro-ischemic cerebral lesion and/or one new microbleeds cerebral lesion | At day-1 before TAVI procedure, at 6 months and at 1 year after procedure | 
| Clinical and Biological predictors of new cerebral events | The clinical (measured before the procedure) and biological characteristics of the patients (measured before the procedure and after the procedure) and of the peri-procedural parameters associated with the occurrence of new events detected on post-procedural MRI (new ischemic and/or new microbleeds cerebral lesion appearing on post-procedural MRI) | At day-1 before TAVI procedure, at 6 months and at 1 year after procedure | 
| Hemostasis predictors of new cerebral events | Hemostasis parameters (measured before the procedure and after the procedure) including Willebrand factor parameters associated with the occurrence of new events detected on postoperative MRI (new ischemic and/or new microbleeds cerebral lesion) | At day-1 before TAVI procedure, at 6 months and at 1 year after procedure | 
| Number of complications in peri-procedural according to VARC-2 criteria | Evaluation of multi criteria according to the Valve academic Research Consortium (VARC-2) | Within one week after the procedure | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Aortic stenosis, Transaortic valve replacement, stroke, Epigenetic