Embolic Cerebral Insults After Transapical Aortic Valve Implantation Detected by Magnetic Resonance Imaging

Arnold, Martin; Schulz-Heise, Susanne; Achenbach, Stephan; Ott, Sabine; Dörfler, Arnd; Ropers, Dieter; Feyrer, R.; Einhaus, Friedrich; Loders, S; Mahmoud, F. O.; Roerick, Olaf; Daniel, Werner G.; Weyand, Michael; Ensminger, Stephan; Ludwig, Josef

doi:10.1016/j.jcin.2010.09.008

Cited by 105 publications

(56 citation statements)

References 23 publications

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“…2,[13][14][15] Brain MRI studies have established subclinical procedure-related cerebral diffusion-weighted imaging abnormalities in up to 80% of cases after TAVR, approximately double the rate that has been reported after surgical aortic valve replacement. 6,7,[14][15][16][17][18] Independent neurological assessment of TAVR patients is not routinely performed, and, thus, some subtle neurological defects may go unrecognized; however, many emboli likely travel to clinically silent areas of the brain. These new cerebrovascular embolic events may not be trivial, because subclinical microinfarctions may be associated with neurocognitive decline and premature dementia.…”

Section: Discussionmentioning

confidence: 99%

Histopathology of Embolic Debris Captured During Transcatheter Aortic Valve Replacement

Mieghem

Schipper

Ladich³

et al. 2013

Circulation

219

144

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Background— Recent transcatheter aortic valve replacement studies have raised concerns about adverse cerebrovascular events. The etiopathology of the embolized material is currently unknown. Methods and Results— A total of 40 patients underwent transcatheter aortic valve replacement with the use of a dual filter–based embolic protection device (Montage Dual Filter System, Claret Medical, Inc). Macroscopic material liberated during the transcatheter aortic valve replacement procedure was captured in the device filter baskets in 30 (75%) patients and sent for histopathologic analysis. The captured material varied in size from 0.15 to 4.0 mm. Amorphous calcified material (size, 0.55–1.8 mm) was identified in 5 patients (17%). In 8 patients (27%), the captured material (size, 0.25–4.0 mm) contained valve tissue composed of loose connective tissue (collagen and elastic fibers) with focal areas of myxoid stroma, with or without coverage by endothelial cells and intermixed with fibrin. In another 13 (43%) patients, collagenous tissue, which may represent elements of vessel wall and valvelike structures, was identified. In 9 patients (30%), thrombotic material was intermixed with neutrophils (size, 0.15–2.0 mm). Overall, thrombotic material was found in 52% of patients, and tissue fragments compatible with aortic valve leaflet or aortic wall origin were found in 52% (21/40) of patients. Conclusions— Embolic debris traveling to the brain was captured in 75% of transcatheter aortic valve replacement procedures where a filter-based embolic protection device was used. The debris consisted of fibrin, or amorphous calcium and connective tissue derived most likely from either the native aortic valve leaflets or aortic wall.

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Section: Discussionmentioning

confidence: 99%

Histopathology of Embolic Debris Captured During Transcatheter Aortic Valve Replacement

Mieghem

Schipper

Ladich³

et al. 2013

Circulation

219

144

View full text Add to dashboard Cite

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“…42 devices and approaches ( Figure 5). 35,[43][44][45][46][47] Analysis of diffusionweighted (DW) MRI studies performed pre-and post-TAVI includes a cumulative total of only 222 patients. TA-TAVI with ES was performed in 68 of these patients, with 52 (76.5%) having newly identified ischemic lesions on MRI postprocedure, and 2 (2.9%) with clinically manifest CVEs.…”

Section: Diffusion-weighted Mrimentioning

confidence: 99%

“…43 Although early studies using DW-MRI supported this, 43,47 the association has not been confirmed by more recent studies. 35,[44][45][46] Similarly, although findings have been inconsistent, there is the suggestion of increased vulnerability of the anterior circulation in comparison with the posterior circulation, with a preponderance for new ischemic lesions in the middle cerebral artery territories. 35,44,45 Not surprisingly, the incidence and volume of preoperative silent ischemic lesions (present in 70% of patients) predicted the occurrence of new postoperative lesions.…”

Section: Diffusion-weighted Mrimentioning

confidence: 99%

Characterization of Neurological Injury in Transcatheter Aortic Valve Implantation

et al. 2014

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“…Furthermore, the average 30-day mortality in TAVR patients with post-procedural stroke was more than 3.5-fold higher than in non-stroke patients (25.5 vs. 6.9) [3]. In addition to the clinically apparent ischemic brain lesions, several cerebral magnetic resonance imaging studies have shown a very high (58-91 %) incidence of new ischemic lesions after TAVR, regardless of the transcatheter valve type and approach (Table 1) [4][5][6][7][8][9]. These small, usually asymptomatic, DWI lesions are most probably caused by micro-embolic particles arising during the valve implantation procedure.…”

Section: Introductionmentioning

confidence: 99%

Silent ischemic brain lesions after transcatheter aortic valve replacement: lesion distribution and predictors

et al. 2015

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Aims Silent ischemic brain lesions and ischemic stroke are known complications of transcatheter aortic valve replacement (TAVR). We aimed to investigate the occurrence and distribution of TAVR-related silent ischemic brain lesions using diffusion-weighted magnetic resonance imaging (DWI). Methods Consecutive patients with severe aortic valve stenosis treated with TAVR underwent cerebral DWI within 5 days after the index procedure. DWI scans were analyzed for the occurrence and distribution of new ischemic lesions post-TAVR. Results Forty-two patients were enrolled in this study. After TAVR, a total of 276 new cerebral ischemic lesions were detected in 38 (90 %) patients, with a median of 4.5 (interquartile range 2.0-7.0) lesions per patient. A total of 129 (47 %) lesions were detected in the cortical regions, 97 (35 %) in the subcortical regions, and 50 (18 %) in the cerebellum or brainstem. The median lesion volume was 20.2 ll (10.0, 42.7) and the total ischemic lesion volume was 132.3 ll (42.8, 336.9). The new ischemic brain lesions were clinically silent in 37 (97 %) patients; the other patient had a transient ischemic attack. Age (B = 0.528, p = 0.015), hyperlipidaemia (B = 5.809, p = 0.028) and post-dilatation of the implanted prosthesis (B = 7.196, p = 0.029) were independently associated with the number of post-TAVR cerebral DWI lesions. In addition, peak transaortic gradient was independently associated with post-procedural total infarct volume. Conclusion Clinically silent cerebral infarcts occurred in 90 % of patients following TAVR, most of which were small (\20 ll) and located in the cortical regions of the cerebral hemispheres. An independent association was found between age, hyperlipidaemia and balloon postdilatation and the number of post-TAVR ischemic brain lesions. Only peak transaortic gradient was independently associated with post-procedural total infarct volume.

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Embolic Cerebral Insults After Transapical Aortic Valve Implantation Detected by Magnetic Resonance Imaging

Cited by 105 publications

References 23 publications

Histopathology of Embolic Debris Captured During Transcatheter Aortic Valve Replacement

Histopathology of Embolic Debris Captured During Transcatheter Aortic Valve Replacement

Characterization of Neurological Injury in Transcatheter Aortic Valve Implantation

Silent ischemic brain lesions after transcatheter aortic valve replacement: lesion distribution and predictors

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