Novel approaches for prevention of stroke related to transcatheter aortic valve implantation

Abstract

Transcatheter aortic valve implantation (TAVI) has emerged as a therapeutical option in patients with aortic stenosis. The methodology has evolved rapidly throughout the last decade. Nowadays, peri-procedural circulatory support, surgical vascular access, general anesthesia and mechanical ventilation are mainly reserved for selected patients. However, numerous challenges need to be addressed in order to further improved outcome of this distinct cohort: patient selection in general, vascular access strategies, long-term valve performance and paravalvular leakage. Another key issue is the risk of cerebrovascular events related to TAVI. In this article, the authors review the current literature on the risk of cerebrovascular events, the underlying mechanisms, the diagnostic read-outs of cerebral injury and their prognostic value, and ultimately discuss conceivable concepts for prevention of stroke associated with TAVI.

Keywords::

• aortic stenosis
• aspirin
• clopidogrel
• dementia
• DW-MRI
• embolism
• filter
• stroke
• TIA
• warfarin

Financial & competing interests disclosure

E Grube is a proctor for CoreValve/Medtronic. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• • The risk of cerebrovascular events related to transcatheter aortic valve implantation (TAVI) was reported to be as high as up to 10% throughout the last decade. Recent data of randomized trials, large-scale registries and meta-analyses report on an annual stroke risk of 3%.

• • Underlying atherosclerotic burden reflected in calcification of the aortic arch, peripheral and cerebrovascular disease, as well as chronic and new-onset of atrial fibrillation are predictors of early and late cerebrovascular events related to TAVI.

• • Optimization of valve sizing and minimizing manipulation of the aortic arch and the native valve are keys to reduce the risk of neurological events.

• • To date, repetitive cerebral diffusion-weighted MRI seems to be the most suitable tool to investigate embolic burden of protective approaches in randomized, controlled trials.

• • Lipid-lowering, antithrombotic and anticoagulant regimens, as well as procedural protocols encompassing embolic protection devices and ‘direct’ TAVI have to be investigated for possible neuroprotective effects.

Notes