Stroke After Transcatheter Aortic Valve Replacement: Incidence, Risk Factors, Prognosis, and Preventive Strategies

Abstract

The first transcatheter aortisc valve replacement (TAVR) was performed in 2002, and has been proven beneficial in inoperable and high‐risk patients for open heart surgery. Stroke occurrence after TAVR, both periprocedure and at follow‐up, has not been well described. We sought to review incidence, pathophysiology, predictors, prognosis, and current preventive strategies of cerebrovascular accidents (CVAs) after TAVR. Studies were selected from a Medline search if they contained clinical outcomes data after TAVR. Acute and subacute CVAs after TAVR have been reported in 3% to 6% of patients. Approximately 45% of CVAs occur within 2 days after TAVR; 28% between 3 and 10 days; 4% between 10 and 30 days; and 10.5% occur from 1 month to 2 years. Clinically silent cerebral embolisms have been reported, with an incidence greatly exceeding that of overt CVAs. Underlying pathophysiologic mechanisms for CVAs can be broadly categorized into embolic and nonembolic causes, as well as procedural and postprocedural (early and late). Important predictors of early CVAs are small aortic valve area, atrial fibrillation, and balloon postdilation, whereas late CVAs are mostly influenced by chronic atrial fibrillation, prior cerebrovascular disease, and transapical approach. Following stroke, patients exhibit increased morbidity and mortality. A multilevel approach for the prevention of CVAs includes improved interventional techniques, embolic protection devices, antithrombotic treatment, close monitoring, and aggressive management of modifiable risk factors. Technology advances notwithstanding stroke morbidity and mortality remains steady. The significance of silent cerebral embolism on prognosis remains uncertain, and optimal medical treatment during and after TAVR should be further investigated.

Temporal trends in transcatheter aortic valve implantation, 2008–2014: patient characteristics, procedural issues, and clinical outcome

“…The event rates for periprocedural stroke, MI, tamponade, major vascular complications, and in‐hospital mortality were all small, and no temporal trends were identified. Similar periprocedural stroke rate and temporal consistent were reported in other studies, although the TVT did demonstrate a statistically significant (but numerically/clinically very small) reduction in periprocedural MI . Although other studies did find a temporal decrease in the rate of vascular complications, we did not.…”

“…[22][23][24] In line with our findings, a recent report on the temporal trends from the UK TAVI registry 25 The event rates for periprocedural stroke, MI, tamponade, major vascular complications, and in-hospital mortality were all small, and no temporal trends were identified. Similar periprocedural stroke rate and temporal consistent were reported in other studies, 14,27,28 although the TVT did demonstrate a statistically significant (but numerically/clinically very small) reduction in periprocedural MI. 14…”

Transcatheter Aortic Valve Implantation in Lower-Risk Patients With Aortic Stenosis

“…13 In Placement of Aortic Transcatheter Valves (PARTNER) 1 trial, 25 periprocedural stroke was associated with ≈2-to 6-fold increase in hospital mortality, a 3-to 12-fold increase in mortality at 30-day, and a 2-to 16-fold increase in longterm mortality. 26 However, although periprocedural stroke or transient ischemic attack was more common after TAVI than after SAVR at 30 days (5.5% versus 2.4%; P=0.04), this difference gradually decreased and by 5 years, the difference had dissipated (TAVI, 14.7% versus SAVR, 15.9%). 27 One concern about interpreting PARTNER trial results is that a neurologist was not involved in the neurological assessment of patients, with potential under-reporting of neurological events.…”

“…25 High-intensity transient signals have been detected by transcranial Doppler in all patients undergoing TAVI using a balloon or a self-expandable prosthesis through a transfemoral or a transapical approach. 26 In the UK TAVI registry, periprocedural stroke was shown as the strongest independent procedural predictor of long-term mortality (hazard ratio, 3.00; P<0.0001). 13 In Placement of Aortic Transcatheter Valves (PARTNER) 1 trial, 25 periprocedural stroke was associated with ≈2-to 6-fold increase in hospital mortality, a 3-to 12-fold increase in mortality at 30-day, and a 2-to 16-fold increase in longterm mortality.…”

Transcatheter aortic valve implantation: initial experience in Hong Kong

“…18 The aetiology of stroke after TAVI is multifactorial and includes embolism of valvular material during balloon valvuloplasty, device manipulation across an atheromatous aorta, and atrial fibrillation. 19 Multiple strategies to reduce periprocedural stroke have been attempted including direct stenting, avoidance of pre-or post-dilation, use of cerebral protection devices and different antithrombotic regimens. 20,21 Currently, randomised trials are underway to determine whether cerebral protection devices are useful in reducing periprocedural stroke.…”