Should We Treat Stroke Percutaneously in TAVR?

Since its inception, transcatheter aortic valve replacement (TAVR) has improved greatly. However, there still are five big challenges to be solved: paravalvular leak, conduction disturbances, debilitating stroke, impaired kidney function, and major vascular complications and bleeding.

¿Debemos realizar tratamiento percutáneo de los strokes en el TAVI?

Most cases of stroke are periprocedural and ischemic. So far, they have not been well analyzed in terms of their severity and resulting level of impairment in abilities. We also do not know which is the best treatment for each particular case.

The analysis included a total of 387 patients with stroke. Of these, 349 received conservative treatment (CT) and 39 received neurointervention (NI).

Stroke events were classified according to the National Institutes of Health Stroke Scale (NIHSS). Mild stroke had a score 0-5, moderate stroke had a score 6-14, and severe stroke were all events with a score ≥15.

Mean patient age was 81 years old; 52% of patients were male, 35% had diabetes, 13% had undergone previous myocardial revascularization surgery, 17% had experienced a previous infarction, 33% had undergone previous coronary angioplasty, and 35% had atrial fibrillation. The Society of Thoracic Surgeons mortality score was 5.9%.

Out of the patients who underwent TAVR, 12% did so in their bicuspid aortic valve, and 1.6% were valve-in-valve.

General anesthesia was used in 35% of cases, and self-expandable valves in 61%.

Stroke occurred within the first day (0-2 days).

The most frequent stroke severity was mild, in 146 patients (49.6%), followed by severe in 75 (25.6%) and moderate in 73 (24.8%). The middle cerebral artery was the most frequently affected artery.

The NIHSS score was higher in patients who received NI (4 vs. 14 p < 0.001), and this strategy was used more frequently in cases of moderate or severe stroke (109 in the TC group and 36 in the NI arm).

Overall mortality at 30 days was 23.1%, at 6 months was 35%, and at 1 year was 42.1%. Moderate and severe stroke had a mortality 1.3 and 4.99 times higher compared with mild stroke, respectively.

There was no difference in mortality according to the degree of stroke severity between the two strategies at follow-up.

A logistic regression analysis was conducted and it showed that, in cases of severe stroke, the NI strategy increased 2.9 times the chance of survival at 90 days.

Conclusion

Acute ischemic stroke after TAVR has a high morbimortality risk correlated with stroke severity. Findings from this analysis suggest that patients with moderate or severe stroke could potentially improve with time after the intervention. It also highlights the importance of collaboration between cardiologists and neurologists to improve the evolution of acute ischemic stroke after TAVR.