Transcranial Doppler-detected cerebral embolic load during transcatheter aortic valve implantation

Abstract

HITS are observed during all procedural intervals in TAVI. The embolic events appear to peak during DP. In our series, the overall cerebral embolic load did not differ between the transfemoral and the transapical access route. TCD monitoring in TAVI is useful to identify periods and manipulations associated with an increased cerebral embolic load and may help to further enhance the safety of this procedure.

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

“…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. Transient expansion and recoil of a metallic stent frame within a partially disrupted native valve (due to pre-dilatation) is probably a particularly efficient way to generate embolic particles, although the prosthesis itself may provide some embolic protection.…”

Letter by Erdoes et al Regarding Article, “Cerebral Embolization During Transcatheter Aortic Valve Implantation: A Transcranial Doppler Study”

“…The results corroborate our previous findings in 67 consecutive patients undergoing transfemoral and transapical TAVI with self-expanding and balloon-expandable prostheses. 2 Both series revealed procedural high-intensity transient signals in all patients, with the highest load during deployment of transfemorally introduced self-expanding prostheses. We also concur with most of the recommendations to reduce the risk of periprocedural cerebral embolism, including reduction of mechanical trauma to aortic intimal surfaces and valvular calcifications, avoidance of long-lasting preimplantation maneuvers, etc.…”

Cerebral Embolization During Transcatheter Aortic Valve Implantation

“…Additional embolic events were routinely observed with repositioning. Also using TCD, Erdoes et al 8 found significantly more embolic events with CoreValve than with SAPIEN during deployment and postimplant interventions such as postdilation and repositioning.…”

“…4,9 One pattern seems clear, that the highest risk of microemboli is during manipulation of the aortic valve itself, particularly when this involves the bulky prosthesis: crossing, positioning, expansion, and postimplant manipulation. 4,8,10 Does Access Affect Stroke Risk? Kahlert et al 4 found no overall difference in the rates of cerebral microemboli with the transfemoral and transapical approaches to TAVI.…”

“…9,11 Rodés-Cabau found no difference with cerebral MRI when transapical and transarterial approaches were compared. 4,8,12 However, 2 recent meta-analyses did suggest a lower stroke risk with transapical TAVI. Comparing transapical and transarterial access with the balloon expandable SAPIEN valve Eggebrecht found a neurological event rate (stroke/transient ischemic event) of 2.7% versus 4.2%.…”