“Not in my brain”: The use of embolic protection devices to prevent brain embolization during cardiovascular procedures

Abstract

In this issue of the Journal, Ranganath and colleagues 1 creatively used cerebral embolic protection devices (EPDs) routinely used during carotid stenting to prevent embolization to the brain during the removal of an Impella (Abiomed, Danvers, Mass) device that had been used without anticoagulation. The devices captured thromboembolic material, and the patient recovered with no neurologic complications. The medical literature is full of procedures and treatments that have a logical and thoughtful foundation, but their implementation has been associated with increased risk or has been difficult to demonstrate that they achieved their proposed objective. Prophylactic procedures aimed to prevent complications should demonstrate effectiveness, and their implementation should be associated with low risk. There are no more important prophylactic procedures than those aimed to the prevention of clinical or radiologic strokes during cardiovascular procedures. Clinical strokes after cardiovascular procedures are fortunately rare, but the majority of patients have clinical silent strokes detected on diffusion-weighted magnetic resonance imaging (dw-MRI) of the brain. 2 dw-MRI of the brain typically demonstrates 1 to 5 small (1-3 mm) bright lesions in 8% to more than 90% of patients after cardiovascular procedures (Figure 1). 2 These lesions represent acute ischemia and may progress to irreversible infarct and tissue loss, although some of them disappear after a few months. 2-5 Clinical strokes after cardiac surgery, coronary interventions, or transcatheter valve and aortic procedures not only decrease survival but also worsen quality of life. Even patients who experience clinical silent strokes (''bright lesions'' on dw-MRI) have poor long-term outcomes with an increased incidence of cognitive dysfunction, dementia, and memory loss. 2-5 Several attempts have been made to prevent embolic strokes during cardiac surgery and other cardiovascular procedures. In a recent Cardiothoracic Surgical Trials Network-sponsored clinical trial (clinicaltrials.gov