Predictors, Incidence, and Outcomes of Patients Undergoing Transfemoral Transcatheter Aortic Valve Implantation Complicated by Stroke

Abstract

Background: Stroke remains one of the most devastating complications of transcatheter aortic valve implantation (TAVI). The aim of this study was to identify the incidence, timing, temporal trends, and predictors of stroke after TAVI and evaluate the outcomes of patients with stroke. Methods and Results: The CENTER-Collaboration is an international collaboration consisting of 3 national registries and 7 local registries or prospective clinical trials, selected through a systematic review. Accordingly, a total of 10 982 patients undergoing transfemoral TAVI between 2007 and 2018 were included in the current patient-level pooled analyses. A total of 261 patients (2.4%) experienced stroke during the first month after TAVI. The median time between TAVI and stroke was 1 day (interquartile range, 0–6 days). The stroke rate was comparable in procedures performed in the early years of TAVI (2007–2012) to those in the more recent years of TAVI (2013–2018; both 2.4%; P =1.0). Independent predictors of stroke at 30 days were a history of cerebrovascular events (odds ratio, 2.2; 95% CI, 1.4–3.6; P =0.0012) and a glomerular filtration rate of <30 mL/min per 1.73 m 2 (odds ratio, 1.7; 95% CI, 1.0–2.8; P =0.05). Stroke occurring within the first 30 days after TAVI was associated with a 6-fold increase of 30-day mortality (odds ratio, 6.0; 95% CI, 4.4–8.1; P <0.001). Moreover, patients with stroke more frequently had documented new-onset atrial fibrillation (16% versus 3%; P <0.001) and major or life-threatening bleedings (12% versus 7%; P =0.002) at 30-day follow-up. Conclusions: In this large, global, patient-level analysis, the incidence of stroke after transfemoral TAVI was 2.4%. Prior cerebrovascular events and a low glomerular filtration rate independently predicted the occurrence of stroke after TAVI. The occurrence of stroke after TAVI was associated with a strikingly 6-fold increase of 30-day mortality; additionally, there was a 5-fold higher rate of new-onset atrial fibrillation in patients with stroke. Clinical Trial Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT03588247.

Aortic valve calcification volumes and chronic brain infarctions in patients undergoing transcatheter aortic valve implantation

“…Transcatheter aortic valve implantation (TAVI) has been established as an effective treatment of severe aortic valve (AV) stenosis, reducing both clinical symptoms and mortality. Nevertheless, one of the most feared complications, namely the occurrence of stroke, is still observed in 2.4% of the patients undergoing TAVI [1]. This complication is observed despite the expansion to low-risk populations, the increase in operator experience and the development of improved valve-systems [2].…”

“…The cerebral emboli during TAVI are attributed to the dislodgement of aortic arch calcifications during the advancement of the catheter through the orifice and the expansion of the implanted valve crushing the calcified native valve [3]. Our previous research showed that stroke after TAVI is associated with poor outcomes, including a sixfold increase of procedural mortality [1]. Nevertheless, clinically overt strokes are only the tip of the iceberg, since shortly after TAVI acute silent cerebral infarctions are visible with diffusion-weighted magnetic resonance imaging (DW-MRI) in up to 78% of the patients [4].…”

Cerebral Protection Devices during Transcatheter Interventions: Indications, Benefits, and Limitations

“…For a detailed review on SBIs after TAVI, we recommend reading the article of Pagnesi et al [40] Risk Factors for Occurrence of CVEs Several risk factors for CVEs were identified, but they differ among studies, in particular depending on patient characteristics, including parameters, definition of events, and time points of assessment. Previous cerebrovascular disease and older age are two independent risk factors associated with early and late CVEs after TAVI and within the general population [41][42][43][44][45]. In an analysis of 10,982 patients from the CENTER collaboration, a GFR < 30 ml/min/1.73 cm 2 was an independent predictor of stroke at 30 days after TAVI [44].…”

“…Previous cerebrovascular disease and older age are two independent risk factors associated with early and late CVEs after TAVI and within the general population [ 41 – 45 ]. In an analysis of 10,982 patients from the CENTER collaboration, a GFR < 30 ml/min/1.73 cm 2 was an independent predictor of stroke at 30 days after TAVI [ 44 ]. In another analysis, post-dilatation and valve dislodgement/embolization were independent predictors of an acute (≤ 24 h) CVE [ 43 ].…”

High-Sensitivity C-Reactive Protein in Transcatheter Aortic Valve Implantation: Prognostic Biomarker and New Potential Therapeutic Avenue

“…Data from the international CENTER collaboration study (10,982 patients undergoing transfemoral TAVI) indicate a 30-day risk of stroke of 2.4% after TAVI, which was responsible for a 6-fold increase of 30-day mortality. 8 Independent predictors of stroke were previous cerebrovascular events and renal insufficiency. Strikingly, this study showed that stroke rate did not decline from the early years of TAVI procedures to more recent years.…”