Cerebral Embolization During Transcatheter Aortic Valve Implantation

Abstract

Background-Transcatheter aortic valve implantation (TAVI) is associated with a higher risk of neurological events for both the transfemoral and transapical approach than surgical valve replacement. Cerebral magnetic resonance imaging has revealed more new, albeit clinically silent lesions from procedural embolization, yet the main source and predominant procedural step of emboli remain unclear. 001).Overall, there were no significant differences between transfemoral and transapical TAVI or between the MCV and ES prostheses. No HITS were detected at baseline or 3-month follow-up. There was 1 major procedural stroke that resulted in death and 1 minor procedural stroke with full recovery at 3-month follow-up in the MCV group. Conclusions-Procedural HITS were detected by transcranial Doppler in all patients. Although no difference was observed between the transfemoral and the transapical approach with the balloon-expandable ES stent valve, transfemoral TAVI with the self-expandable MCV prosthesis resulted in the greatest number of HITS, predominantly during implantation. (Circulation. 2012;126:1245-1255.)

Characterization of Neurological Injury in Transcatheter Aortic Valve Implantation

“…Kahlert et al, 7 in the largest and most comprehensive study investigating TCD-detected emboli, demonstrated the highest number of HITS during the implantation stage with the MCV, suggesting that the stent acts to scrape calcific debris and valve tissue from the native aortic valve during the slow release of the prosthesis. Conversely, more HITS were identified while positioning the ES valve, which, because of rapid expansion, necessitates more precision and is therefore more time-consuming.…”

“…53 Overall, however, the aortic arch appears to play only a minor role in comparison with the significant embolic burden associated with the manipulation of the aortic valve during device positioning and implantation. 7 …”

“…6 In fact, cerebral embolism is a universal finding associated with these procedures. 7 Most events, however, are subclinical or silent, with clinically apparent CVEs representing but the tip-of-the-iceberg. As a result of the difficulty ascertaining these subclinical events, the true association between TAVI and neurological injury is unknown and the harm potentially underestimated.…”

Cerebral Protection During Transcatheter Aortic Valve Implantation: An Updated Systematic Review and Meta‐Analysis

“…Nonetheless, along with groundbreaking efficacy results, data concerning the risk of cerebrovascular complications have been consistently reported in studies using either diffusion‐weighted magnetic resonance imaging (DW‐MRI) or high‐intensity transient signals as assessed by transcranial Doppler 7, 8, 9, 10. Embolic protection devices (EPDs) have been ideated and introduced with the aim of reducing such an inherent risk, but they have been tested in relatively small populations, providing inconclusive results.…”

Motion-adapted catheter navigation with real-time instantiation and improved visualisation

“…To this end, methods based on 3D model-based registration [4,5] and predictive adaptation during image-guided intervention [6] have been developed. With aortic branch cannulation, there is a chance of aortic dissection or plaque dislodgement, risking possible stroke, if the robotic catheter is not advanced with care through the dynamic vasculaturethere is a particular risk of cerebral embolisation during endovascular procedures in the aortic arch [7]. The aortic arch and its branches are affected by the cardiac cycle through two mechanisms: firstly, the proximity of the aorta to the myocardium during contraction and, secondly, the haemodynamic effects caused by the pulsatile blood flow.…”