A High-Risk Period for Cerebrovascular Events Exists After Transcatheter Aortic Valve Implantation

Abstract

The incidence of CeV events is highest within 24 h of TAVI, but this risk may remain elevated for up to 2 months. A prior history of cerebrovascular disease is an independent predictor. This may have implications for patient selection and antithrombotic strategies.

Comparison of dual antiplatelet therapy versus oral anticoagulation following transcatheter aortic valve replacement: A retrospective single-center registry analysis

“…Most cardioembolic events after TAVR were reported to occur within the first days after TAVR [15]. In the present study, the incidence of all-cause mortality, stroke and MI at 30 days was comparable to results previously published in prospective landmark trials as well as nationwide registries [16][17][18][19][20].…”

Characterization of Neurological Injury in Transcatheter Aortic Valve Implantation

“…Before endothelialization, the stent of the valve may be thrombogenic-a process that has been shown to be incomplete out to 425 days postimplantation. 5,39 Additionally, the high forces required for valve crimping and balloon dilation cause structural damage to the prosthetic valve leaflets, resulting in a prothrombotic state with platelet and fibrin aggregation demonstrated within hours of implantation. 5 In addition to acting as a persistent nidus for calcific emboli, the native leaflets too undergo prothrombotic structural changes, including fissuring and endothelial denudation.…”

“…5,39 Additionally, the high forces required for valve crimping and balloon dilation cause structural damage to the prosthetic valve leaflets, resulting in a prothrombotic state with platelet and fibrin aggregation demonstrated within hours of implantation. 5 In addition to acting as a persistent nidus for calcific emboli, the native leaflets too undergo prothrombotic structural changes, including fissuring and endothelial denudation. Altered rheology resulting from native leaflet compression against the aortic wall, paravalvular leak, and apical infarction caused by transapical access may similarly be thrombogenic.…”

“…5 This elevated early risk reflects the increased incidence of ischemic stroke thought secondary to particulate emboli dislodged by the procedure itself or as a result of thromboembolism. 6 In fact, cerebral embolism is a universal finding associated with these procedures.…”

Antithrombotic Regimens in Patients Undergoing Transcatheter Aortic Valve Implantation

“…1-3 TAVI has similar mortality rates but superior quality of life in comparison with surgical AVR; 4 however, periprocedural thromboembolic complications and post-TAVI cerebrovascular events are clinically relevant, and antithrombotic treatment is therefore thought to play an important role in stroke prevention in the prothrombotic environment of the bioprosthesis. 5 It is widely accepted to prescribe clopidogrel in addition to aspirin for a 3-to 6-month period after TAVI, but this approach is not evidence-based, and evidence is lacking about the antithrombotic regimens of single-antiplatelet (SAPT), dual-antiplatelet (DAPT), or warfarin in patients undergoing TAVI ( Figure).…”