Insights Into Timing, Risk Factors, and Outcomes of Stroke and Transient Ischemic Attack After Transcatheter Aortic Valve Replacement in the PARTNER Trial (Placement of Aortic Transcatheter Valves)

Abstract

T ranscatheter aortic valve replacement (TAVR) has revolutionized management of elderly patients with severe aortic stenosis, 1,2 but post-TAVR neurological events remain a concern for patients and physicians. Although occurrence of post-TAVR stroke has fallen from ≈5% in initial trials to 3% in recent reports, reducing this risk is essential for advancing this technology into lower-risk patient cohorts. See Editorial by Dangas and GiustinoUnderstanding the mechanisms of neurological events is critical for developing strategies for reducing their occurrence. Despite several attempts to identify procedure and patient characteristics that may lead to neurological events, the field remains somewhat controversial.3,4 One controversy is the timing of neurological events and its relationship to procedural embolization.5 Different reports have suggested that up to half of the events may be unrelated to procedural embolization, although small numbers of patients and events, Background-Prior studies of stroke and transient ischemic attack (TIA) after transcatheter aortic valve replacement (TAVR) are limited by reporting and follow-up variability. This is a comprehensive analysis of time-related incidence, risk factors, and outcomes of these events. Methods and Results-From 17).Stroke and TIA were associated with lower 1-year survival than expected (TF 47% after stroke versus 82%, and 64% after TIA versus 83%; TA 53% after stroke versus 80%, and 64% after TIA versus 83%). Risk factors for early stroke after TA-TAVR included more postdilatations, pure aortic stenosis without regurgitation, and possibly more pacing runs, earlier date of procedure, and no dual antiplatelet therapy; high pre-TAVR aortic peak gradient was a risk factor for stroke early after TF-TAVR. Conclusions-Risk of stroke or TIA is highest early after TAVR and is associated with increased 1-year mortality.Modifications of TAVR, emboli-prevention devices, and better intraprocedural pharmacological protection may mitigate this risk. Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT00530894.(Circ Cardiovasc Interv. 2016;9:e002981.

Impact of pre‐existing or new‐onset atrial fibrillation on 30‐day clinical outcomes following transcatheter aortic valve replacement: Results from the BRAVO 3 randomized trial

“…Post‐hoc data from the PARTNER trial and other observational and meta‐analytical studies have shown new‐onset AF to be associated with greater risk for cerebrovascular events at 30 days. However, despite the anticipated adverse effects of AF, we did not observe statistically significant differences in 30‐day risk of outcomes compared with patients in sinus rhythm in this study.…”

“…The pathophysiology of new‐onset AF post TAVR has been linked with increased left atrial stress from LV dysfunction, and local inflammatory processes from the TAVR procedure inciting ectopic atrial activity . However, the most important risk factor for new‐onset AF is TAVR access, with significantly greater risk from nontransfemoral (non‐TF) approaches . This is hypothesized to be due to nonpercutaneous surgical access, postoperative access site pain and complications including infection triggering inflammatory pathways .…”

Impact of Rapid Ventricular Pacing on Outcome After Transcatheter Aortic Valve Replacement

“…Few studies have correlated RVP with a clinical end point. A sub‐analysis of the PARTNER trial found that in the subgroup of patients undergoing transapical TAVR, a greater number of pacing runs (not pacing duration) showed intermediate association with higher risk for stroke 3. Similarly, a report from the CoreValve trials indicated a higher risk of stroke in patients who underwent RVP for predilation of the aortic valve versus those who did not 8.…”

“…Indeed, prior case reports and small‐scale studies have reported conflicting data on the hemodynamic effects and clinical impact of RVP during TAVR 1, 2, 3, 4. Thus the aim of the present study was to assess the clinical impact of RVP on immediate and long‐term outcomes in a large cohort of non‐selected TAVR patients.…”

Splinting and mechanical disruption of the mitral valve apparatus by an endocardial left ventricular lead while delivering cardiac resynchronization therapy

“…Given it was splinting the mitral valve apparatus, there was concern about potential damage to the valve upon removal in addition to arterial embolization. The risk of embolic stroke during interventions within the arterial system is well described within the transcatheter aortic valve implantation (TAVI) cohort of patients; there is a high prevalence of subclinical infarcts on neurological imaging and clinical cerebrovascular accidents 8. There are, however, no published reports of transcutaneous extraction of endocardial LV leads, and therefore, the prevalence of such complications is unknown.…”