Stroke after transcatheter aortic valve replacement: incidence, risk factors, prognosis, and preventive strategies

Abstract

The first transcatheter aortisc valve replacement (TAVR) was performed in 2002, and has been proven beneficial in inoperable and high-risk patients for open heart surgery. Stroke occurrence after TAVR, both periprocedure and at follow-up, has not been well described. We sought to review incidence, pathophysiology, predictors, prognosis, and current preventive strategies of cerebrovascular accidents (CVAs) after TAVR. Studies were selected from a Medline search if they contained clinical outcomes data after TAVR. Acute and subacute CVAs after TAVR have been reported in 3% to 6% of patients. Approximately 45% of CVAs occur within 2 days after TAVR; 28% between 3 and 10 days; 4% between 10 and 30 days; and 10.5% occur from 1 month to 2 years. Clinically silent cerebral embolisms have been reported, with an incidence greatly exceeding that of overt CVAs. Underlying pathophysiologic mechanisms for CVAs can be broadly categorized into embolic and nonembolic causes, as well as procedural and postprocedural (early and late). Important predictors of early CVAs are small aortic valve area, atrial fibrillation, and balloon postdilation, whereas late CVAs are mostly influenced by chronic atrial fibrillation, prior cerebrovascular disease, and transapical approach. Following stroke, patients exhibit increased morbidity and mortality. A multilevel approach for the prevention of CVAs includes improved interventional techniques, embolic protection devices, antithrombotic treatment, close monitoring, and aggressive management of modifiable risk factors. Technology advances notwithstanding stroke morbidity and mortality remains steady. The significance of silent cerebral embolism on prognosis remains uncertain, and optimal medical treatment during and after TAVR should be further investigated.

Figure 1

Registry‐based incidence of major and minor stroke after TAVR in current clinical practice. Abbreviations: ACC, American College of Cardiology; TAVR, transcatheter aortic valve replacement; TVT, TransValvular Therapy registry. Data are from Rodes‐Cabau et al.,6 Thomas et al.,7 Eltchaninoff et al.,8 Piazza et al.,9 Tamburino et al.,41 Zahn et al.,10 Bosmans et al.,11 Moat et al,12 Gilard et al.,13 Avanzas et al.,14 Nombela‐Franco et al.,36 Mack et al.,57 Popma et al.21

Figure 2

Timing of stroke after TAVR with approximately 2 years follow‐up. Each bar‐chart represents the percentage of strokes out of the total individual study strokes. Abbreviations: PARTNER, Placement of Aortic Transcatheter Valves; TAVR, transcatheter aortic valve replacement. Data are from Amat‐Santos et al,34 Nuis et al,35 PARTNER A3 and B,17 and Nombela‐Franco et al.36