Timing, Predictive Factors, and Prognostic Value of Cerebrovascular Events in a Large Cohort of Patients Undergoing Transcatheter Aortic Valve Implantation

Nombela‐Franco, Luis; Webb, John G.; Jaegere, Peter P. de; Toggweiler, Stefan; Nuis, Rutger-Jan; Dager, Antonio; Amat‐Santos, Ignacio J.; Cheung, Anson; Ye, Jian; Binder, Ronald K.; Boon, Robert M. van der; Mieghem, Nicolas Van; Benítez, Luis; Pérez, Sergio; López, Javier; Román, José Alberto San; Doyle, Daniel; DeLarochellière, Robert; Ureña, Marina; Leipsic, Jonathon; Dumont, Éric; Rodés‐Cabau, Josep

doi:10.1161/circulationaha.112.110981

Cited by 381 publications

(278 citation statements)

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“…The association between postdilatation of the aortic valve prosthesis might be due to an increased interaction between the stent frame of the valve prosthesis and the native aortic valve, which might indeed favor the dislodgment of calcific particles from the native valve. One previous study by Nombela-Franco et al [19] reported that further stretching of the calcified native valve during balloon post-dilatation is independently associated with a twofold risk of cerebrovascular events immediately or within the first few hours after the procedure. With regard to procedural risk factors, two previous studies [20] showed that high-intensity transient signals (HITS) observed with TCD occurred during all procedural intervals in TAVR, however, the embolic events appeared to peak during prosthesis deployment.…”

Section: Discussionmentioning

confidence: 98%

Silent ischemic brain lesions after transcatheter aortic valve replacement: lesion distribution and predictors

et al. 2015

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Aims Silent ischemic brain lesions and ischemic stroke are known complications of transcatheter aortic valve replacement (TAVR). We aimed to investigate the occurrence and distribution of TAVR-related silent ischemic brain lesions using diffusion-weighted magnetic resonance imaging (DWI). Methods Consecutive patients with severe aortic valve stenosis treated with TAVR underwent cerebral DWI within 5 days after the index procedure. DWI scans were analyzed for the occurrence and distribution of new ischemic lesions post-TAVR. Results Forty-two patients were enrolled in this study. After TAVR, a total of 276 new cerebral ischemic lesions were detected in 38 (90 %) patients, with a median of 4.5 (interquartile range 2.0-7.0) lesions per patient. A total of 129 (47 %) lesions were detected in the cortical regions, 97 (35 %) in the subcortical regions, and 50 (18 %) in the cerebellum or brainstem. The median lesion volume was 20.2 ll (10.0, 42.7) and the total ischemic lesion volume was 132.3 ll (42.8, 336.9). The new ischemic brain lesions were clinically silent in 37 (97 %) patients; the other patient had a transient ischemic attack. Age (B = 0.528, p = 0.015), hyperlipidaemia (B = 5.809, p = 0.028) and post-dilatation of the implanted prosthesis (B = 7.196, p = 0.029) were independently associated with the number of post-TAVR cerebral DWI lesions. In addition, peak transaortic gradient was independently associated with post-procedural total infarct volume. Conclusion Clinically silent cerebral infarcts occurred in 90 % of patients following TAVR, most of which were small (\20 ll) and located in the cortical regions of the cerebral hemispheres. An independent association was found between age, hyperlipidaemia and balloon postdilatation and the number of post-TAVR ischemic brain lesions. Only peak transaortic gradient was independently associated with post-procedural total infarct volume.

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Section: Discussionmentioning

confidence: 98%

Silent ischemic brain lesions after transcatheter aortic valve replacement: lesion distribution and predictors

et al. 2015

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“…Preexisting AF and new-onset AF have been associated with an increased risk of stroke after TAVR, 36,37 and the occurrence of previously unknown paroxysmal AF/AT may also be associated with an increased rate of 30-day stroke if anticoagulation therapy is not prescribed early. In fact, the occurrence of AF/AT during 24-hour ECG recording was associated with an 18-fold increase in the rate of cerebrovascular events compared with patients with no AF/AT and an almost 2-fold increase compared with patients with previously known AF/AT.…”

Section: Discussionmentioning

confidence: 99%

Arrhythmia Burden in Elderly Patients With Severe Aortic Stenosis as Determined by Continuous Electrocardiographic Recording

et al. 2015

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T he occurrence of new conduction abnormalities and the need for permanent pacemaker implantation (PPI) are frequent complications of transcatheter aortic valve replacement (TAVR) and may potentially jeopardize the use of this technology in a lower-risk and younger population. 1,2 In addition to the aortic stenosis itself, it has been shown that advanced age and comorbidities such as heart failure, hypertension, and diabetes mellitus, all of which are very frequent in candidates for TAVR, are associated with a high prevalence of left bundle-branch block (LBBB) and severe bradyarrhythmias, irrespective of TAVR.3-8 Furthermore, it is well known that these conduction disorders may be paroxysmal and asymptomatic 9 or lead to symptoms similar to those of aortic stenosis, and the occurrence of these abnormalities may therefore be overlooked unless ECG Background-This study sought to evaluate the prevalence of previously undiagnosed arrhythmias in candidates for transcatheter aortic valve replacement (TAVR) and to determine the impact on therapy changes and arrhythmic events after the procedure. Methods and Results-A total of 435 candidates for TAVR underwent 24-hour continuous ECG monitoring the day before the procedure. Newly diagnosed arrhythmias were observed in 70 patients (16.1%) before TAVR: paroxysmal atrial fibrillation (AF)/atrial tachycardia (AT) in 28, advanced atrioventricular block or severe bradycardia in 24, nonsustained ventricular tachycardia in 26, and intermittent left bundle-branch block in 3 patients. All arrhythmic events but one were asymptomatic and led to a therapy change in 43% of patients. In patients without known AF/AT, the occurrence of AF/AT during 24-hour ECG recording was associated with a higher rate of 30-day cerebrovascular events (7.1% versus 0.4%; P=0.030). Among the 53 patients with new-onset AF/AT after TAVR, 30.2% had newly diagnosed paroxysmal AF/AT before the procedure. In patients who needed permanent pacemaker implantation after the procedure (n=35), 31.4% had newly diagnosed advanced atrioventricular block or severe bradycardia before TAVR. New-onset persistent left bundle-branch block after TAVR occurred in 37 patients, 8.1% of whom had intermittent left bundle-branch block before the procedure. Conclusions-Newly diagnosed arrhythmias were observed in approximately a fifth of TAVR candidates, led to a higher rate of cerebrovascular events, and accounted for a third of arrhythmic events after the procedure. This high arrhythmia burden highlights the importance of an early diagnosis of arrhythmic events in such patients to implement the appropriate therapeutic measures earlier.

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“…Recent studies identified balloon post-dilatation and valve dislodgement as acute stroke predictors, while new onset atrial fibrillation (AF) was identified as subacute stroke predictor and age, chronic AF, history of stroke, TIA and peripheral vascular disease or coronary artery disease as late stroke predictors (27)(28)(29)(30). The recently presented Sentinel Trial proved that MRI baseline FLAIR Volumes is a strong predictor of a new lesion volume after TAVR (31).…”

Section: Strokementioning

confidence: 99%

Pros and cons of transcatheter aortic valve implantation (TAVI)

Terre¹,

George²,

Smith³

2017

Ann. Cardiothorac. Surg.

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Transcatheter aortic valve implantation (TAVI) or replacement (TAVR) was recently approved by the FDA for intermediate risk patients with severe aortic stenosis (AS). This technique was already worldwide adopted for inoperable and high-risk patients. Improved device technology, imaging analysis and operator expertise has reduced the initial worrisome higher complications rate associated with TAVR, making it comparable to surgical aortic valve replacement (SAVR). However, many answers need to be addressed before adoption in lower risk patients. This paper highlights the pros and cons of TAVI based mostly on randomized clinical trials involving the two device platforms approved in the United States. We focused our analysis on metrics that will play a key role in expanding TAVR indication in healthier individuals. We review the significance and gave a perspective on paravalvular leak (PVL), valve performance, valve durability, leaflet thrombosis, stroke and pacemaker requirement.

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Timing, Predictive Factors, and Prognostic Value of Cerebrovascular Events in a Large Cohort of Patients Undergoing Transcatheter Aortic Valve Implantation

Abstract: Background-The objective of this study was to evaluate the timing, predictive factors, and prognostic value of cerebrovascular events (CVEs) after transcatheter aortic valve implantation.

Cited by 381 publications

References 41 publications

Silent ischemic brain lesions after transcatheter aortic valve replacement: lesion distribution and predictors

Silent ischemic brain lesions after transcatheter aortic valve replacement: lesion distribution and predictors

Arrhythmia Burden in Elderly Patients With Severe Aortic Stenosis as Determined by Continuous Electrocardiographic Recording

Pros and cons of transcatheter aortic valve implantation (TAVI)

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