Risk of Stroke After Transcatheter Aortic Valve Implantation: Epidemiology, Mechanism, and Management

Abstract

Background: Transcatheter aortic valve implantation (TAVI) has become an established and increasingly used approach for management of severe symptomatic aortic stenosis, showing similar or even superior outcomes compared with standard surgical aortic valve replacement (SAVR). Stroke after TAVI is a relatively rare, but serious complication, associated with potential prolonged disability and increased mortality. Areas of Uncertainty: The overall incidence of 30-day stroke in TAVI patients is 3%–4%, but varies between different trials. Initial data suggested a higher risk of stroke after TAVI when compared with SAVR. The association between subclinical leaflet thrombosis and cerebral embolism, presented as stroke, transient ischemic accident, or silent cerebral ischemia is not entirely elucidated yet. Moreover, TAVI for severe bicuspid aortic stenosis is a relatively new issue, bicuspid anatomy being initially excluded from the pivotal clinical trials investigating TAVI procedure. Efficient stroke prevention strategies are under investigation. Data Sources: In the present manuscript, we used the available published data from the most relevant clinical trials, registries, and meta-analysis of patients from different risk categories who underwent TAVI or SAVR. Therapeutic Advances: Predictors of acute stroke are mainly procedure related. Technological development, improvements in bioprosthesis valve delivery catheters, and implantation technique may explain the decrease of stroke over the years since the beginning of TAVI procedures. Conclusions: The overall evidences confirm similar or lower rate of stroke in TAVI versus SAVR. Risk predictors for acute stroke after TAVI are generally related to procedural factors, whereas late stroke is mainly associated with patient characteristics, with a variable impact on cognitive function. The optimal choice for the antithrombotic treatment in TAVI for stroke prevention is yet to be determined. Current data do not support routine use of cerebral embolic protection devices during TAVI.

Comparisons of different new-generation transcatheter aortic valve implantation devices for patients with severe aortic stenosis: a systematic review and network meta-analysis

“…Our study has demonstrated that Lotus and Sapien 3 had the highest and lowest stroke risk among the newer devices, respectively. Previous studies suggested that most of the TAVI related strokes were embolic and developed mainly intraprocedural 106 . One possible explanation for an increased stroke risk with the Lotus valve could be that repositioning of the retrievable valve may increase the frequency of friction between the valve prosthesis and landing zone, which, in turn, may increase the risk of plaque abrasion, causing embolization and subsequent cerebrovascular events 96 , 97 .…”

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

“…In fact, during TAVR, it is hypothesized that the manipulation of large devices into the aortic arch and through the calcified native valve might mobilize and fragment atherosclerotic plaques that are prone to embolization in the cerebral circulation [ 44 ]. Structural and procedural concerns are considered the major periprocedural risk conditions [ 45 ]: aortic valve area or aortic annulus size, the degree of aortic leaflet calcification, pure aortic stenosis, high gradients, the degree of aortic atherosclerotic burden (such as porcelain aorta), as well as procedure time, repositioning of the bioprosthesis, post-dilation, the degree of anticoagulation, and the experience of the interventionalist. Ischemic stroke occurring >1 year from TAVR is named late stroke, and although its etiology is less understood, it seems to be mainly associated with patient characteristics: new-onset AF, HF, diabetes mellitus, systemic inflammatory diseases, thrombophilia, and chronic kidney disease.…”

Impact of stroke history on procedural cerebrovascular insult probability and long‐term outcome after TAVI

“…Despite the minimal invasive nature of the procedure, complications such as procedural stroke may occur in some patients due to embolisation of debris from the valve or the vasculature. The overall incidence of 30‐day stroke in TAVI patients is 3%–4% 2 . Risk predictors for acute stroke after TAVI are generally related to procedural factors, whereas late stroke is mainly associated with patient characteristics, with a variable impact on cognitive function 2 .…”

“…The overall incidence of 30‐day stroke in TAVI patients is 3%–4% 2 . Risk predictors for acute stroke after TAVI are generally related to procedural factors, whereas late stroke is mainly associated with patient characteristics, with a variable impact on cognitive function 2 . Periprocedural ischemic lesions are frequent but mostly clinically silent.…”