Embolic Protection Devices in Transcatheter Aortic Valve Implantation: A Narrative Review of Current Evidence

Abstract

Transcatheter aortic valve implantation (TAVI) has emerged as a transformative therapy for patients with severe aortic stenosis (AS) across all surgical risk groups. However, periprocedural cerebrovascular events (CVEs), including overt stroke and silent cerebral embolism, remain significant complications. As a result, the use of embolic protection devices (EPDs) during TAVI has been proposed to mitigate this risk. Our aim was to provide a comprehensive review of the current evidence on the efficacy, safety, and clinical utility of embolic protection devices in TAVI procedures. According to the existing literature, EPDs are effective in capturing embolic debris during TAVI and are associated with a reduction in silent cerebral lesions as detected by diffusion-weighted MRI. While some RCTs and meta-analyses demonstrate a potential benefit in reducing disabling stroke, evidence for a consistent reduction in overall stroke or mortality remains inconclusive. Subgroup analyses suggest the greatest benefit in patients at elevated stroke risk, while current-generation EPDs demonstrate high technical success and an acceptable safety profile. Subsequently, EPDs represent a promising adjunct to TAVI, particularly in high-risk populations. However, routine use in all patients is not yet supported by consistent clinical evidence. Further large-scale trials and long-term outcome data are needed to clarify their role in improving neurological outcomes and to guide selective patient application.

Keywords: TAVI; cerebral embolic protection; embolic protection devices; silent infarcts; stroke; transcatheter aortic valve implantation.

Figure 1

Cerebral embolic protection in TAVI. This illustration summarizes the pathophysiology of cerebral embolization during transcatheter aortic valve implantation (TAVI), the types and mechanisms of cerebral embolic protection devices (EPDs), and the current clinical evidence regarding their use. It depicts the release of embolic debris during key procedural steps of TAVI and its potential to cause overt stroke or silent cerebral infarcts. Alongside, it illustrates the three primary categories of EPDs [(A) Filter-based system; (B) Deflector-based system; (C) Complete protection device] and the current evidence and ongoing controversies regarding the clinical efficacy of EPDs. While EPDs effectively reduce the volume of silent brain infarcts and may lower the incidence of disabling stroke in selected patients, no consistent reduction in overall stroke rates or mortality has been demonstrated. The routine use of EPDs remains debated, with current guidelines recommending a selective approach pending results from ongoing large-scale randomized trials.