Fighting Cardiac Thromboembolism during Transcatheter Procedures: An Update on the Use of Cerebral Protection Devices in Cath Labs and EP Labs

Abstract

Intraprocedural stroke is a well-documented and feared potential risk of cardiovascular transcatheter procedures (TPs). Moreover, subclinical neurological events or covert central nervous system infarctions are concerns related to the development of dementia, future stroke, cognitive decline, and increased risk of mortality. Cerebral protection devices (CPDs) were developed to mitigate the risk of cardioembolic embolism during TPs. They are mechanical barriers designed to cover the ostium of the supra-aortic branches in the aortic arch, but newer devices are able to protect the descending aorta. CPDs have been mainly designed and tested to provide cerebral protection during transcatheter aortic valve replacement (TAVR), but their use in both Catheterization and Electrophysiology laboratories is rapidly increasing. CPDs have allowed us to perform procedures that were previously contraindicated due to high thromboembolic risk, such as in cases of intracardiac thrombosis identified at preprocedural assessment. However, several concerns related to their employment have to be defined. The selection of patients at high risk of thromboembolism is still a subjective choice of each center. The aim of this review is to update the evidence on the use of CPDs in either Cath labs or EP labs, providing an overview of their structural characteristics. Future perspectives focusing on their possible future employment are also discussed.

Anticoagulation Intensity during Appendage Occlusion: Lessons from Silent Cerebral Embolism

“…This concern is particularly acute in certain high-risk populations, such as patients with thrombus formation in the LA appendage, for whom the LAAO procedure itself poses a significant threat, as well as those with elevated bleeding risks who may not tolerate more intensive anticoagulation regimens. In light of these considerations, cerebral protection devices have garnered increasing attention in recent years as a potential safeguard [23]. However, strong evidence of the routine use of cerebral protection devices during LAAO remains lacking.…”

Left Atrial Appendage Closure in Patients With Mechanical Mitral Valve Prosthesis: A Multicenter Italian Pilot Study

“…This procedure can be performed also by percutaneous approach and is currently the only nonpharmacologic option for preventing CEs in patients with AF at significant stroke risk. LAAC is a continually expanding indication and may play a key role in cases of OAC failure [11], as suggested by newer studies [12], and availability of cerebral protection devices (CPDs) may further improve procedural outcome [13]. However, since patients with LAA thrombosis and mechanical PMV were excluded in all studies, LAAC is currently off-label in this scenario [14].…”

Challenging Silent Cerebral Embolism during Left Atrial Appendage Occlusion: A Lesson from Recent Studies

“…It is well known that AF causes a worsening of cognitive status that correlates with the presence of brain lesions on MRI [8]; however, it is unclear whether the increased risk of CE during interventional procedures correlates in the same way with a worsening neurological prognosis [9]. Nevertheless, intraprocedural strategies to prevent CE by using appropriate anticoagulation and cerebral protection devices [10] could be adopted to improve cerebral protection. The current recommendation for intraprocedural anticoagulation is to administer with reduced unfractionated heparin for a target activated clotting time (ACT) 250-350 s, although based solely on expert consensus [11,12].…”