Incidence, predictors, origin and prevention of early and late neurological events after transcatheter aortic valve implantation (TAVI): a comprehensive review of current data

Abstract

Transcatheter aortic valve implantation (TAVI) is a novel treatment option for patients with severe, symptomatic aortic valve stenosis considered inoperable or at high risk for surgical aortic valve replacement. Despite rapid adoption of this technology into clinical application, however, recent randomized controlled clinical trials have raised safety concerns regarding an increased risk of neurological events with TAVI compared to both medical treatment and conventional, surgical aortic valve replacement. Moreover, neuro-imaging studies have revealed an even higher incidence of new, albeit clinically silent cerebral lesions as a surrogate for procedural embolization. In this article, we review currently available data on the incidence, timing, predictors, prognostic implications and potential mechanisms of neurological events after TAVI.

Transcatheter aortic valve replacement

“…20 During follow-up, the risk for neurologic events is primarily influenced by patient-related risk factors such as history of stroke, atrial fibrillation, and cerebrovascular disease, not by the procedure chosen. 82 There are studies suggesting that the transapical approach is associated with a reduced risk of stroke, 49 but Khatri et al's meta-analysis could not show a significant difference in the prevalence of stroke between transapical and transarterial TAVR, nor between the SAPIEN valve and CoreValve. 40 An increased risk of stroke is an important aspect when considering TAVR for lower-risk patients.…”

“…21,82 A recent meta-analysis by Khatri et al 40 on adverse events after TAVR reported an early stroke rate of 2.9%. However, several studies have shown that 58%-77% of patients undergoing TAVR have small, silent cerebral infarctions detectable on magnetic resonance imaging with an incidence significantly higher than in patients undergoing SAVR.…”

Stroke Prevention With Carotid Compression in Patients Undergoing Transcatheter Aortic Valve Replacement: a Multi-Center Study

“…Another approach to preventing stroke after TAVR is the use of embolic protection devices. There is evidence to suggest that the use of embolic protection devices is associated with a smaller volume of silent ischemic lesions and a smaller total volume of lesions, but there is no related decrease in clinically relevant strokes [34] and no significant change in neurocognitive function [15,16,24].…”

“…However, a history of carotid disease may be one predictor of post-procedure strokes [11][12][13]. Multiple studies utilizing magnetic resonance imaging, trans-cranial Doppler, and filtered and retrieved material have documented nearly universal embolic phenomena during TAVR [14][15][16][17]. Hypothetically, stroke prevention can be achieved by minimizing the amount of microemboli showering from the aorta to the brain during TAVR implantation.…”

Mobile mass lesion in the aorta after transcatheter aortic valve implantation: Thrombus or residue calcification

“…Even though TAVI is a less invasive treatment compared to the surgical aortic valve replacement, some serious complications may develop. Some of them are aortic rupture [1], early aortic valve thrombosis [2], peripheral [3], and neurological embolization [4] of aortic valve calcium following transcatheter aortic valve implantation. Infective endocarditis [5] and thrombus formation are also potential conditions after TAVI.…”