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%.

Read also: RIPCORD 2 Study: Routine Assessment Using Pressure Wires in Acute Coronary Syndrome

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.

Read also: Are FFR and IVUS Similar to Assess Intermediate Lesions?

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.

Read also: Is TCA Useful for Severe Impairment of Left Ventricular Ejection Fraction?

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.

Dr. Carlos Fava - Consejo Editorial SOLACI

Dr. Carlos Fava.
Member of the Editorial Board of SOLACI.org.

Original Title: Management and Outcome of Acute Ischemic Stroke Complicating Transcatheter Aortic Valve Replacement. on Behalf of the ASTRO-TAVI Study Group.

Reference: Amos Levi, et al. J Am Coll Cardiol Intv 2022. Article in Press.


Subscribe to our weekly newsletter

Get the latest scientific articles on interventional cardiology

More articles by this author

Unplanned Coronary Angiography After TAVR: Incidence, Predictors, and Outcomes

The importance of assessing coronary artery disease in patients undergoing transcatheter aortic valve replacement (TAVR) is well recognized due to the high prevalence of...

TAVR Unload: TAVR in Moderate Aortic Stenosis and Ventricular Function Deterioration

Aortic Stenosis (AS) significantly contributes to valvulo-arterial impedance in patients with heart failure and reduced ejection fraction (HFrEF), making it a relevant therapeutic target...

TAVI and Hypertrophic Cardiomyopathy: An Increasingly Common Association

Stenosis is a common disease affecting 5% of the elderly population. It is associated with hospitalizations, poor quality of life, and mortality.  The association between...

TAVR in Bicuspid Valves: Higher Prosthesis Mismatch?

TAVR indication is steadily advancing onto younger, lower risk patients.  The presence of bicuspid aortic valves (BAV) has been observed in 0.5% to 2% of...

LEAVE A REPLY

Please enter your comment!
Please enter your name here

Related Articles

SOLACI Sessionsspot_img

Recent Articles

Unplanned Coronary Angiography After TAVR: Incidence, Predictors, and Outcomes

The importance of assessing coronary artery disease in patients undergoing transcatheter aortic valve replacement (TAVR) is well recognized due to the high prevalence of...

Intravascular Lithotripsy in Calcified Coronary Lesions: Success Predictors

Coronary artery calcification (CAC) is increasingly common in patients undergoing percutaneous coronary intervention (PCI). Intravascular lithotripsy (IVL) has been established as an effective tool...

TAVR Unload: TAVR in Moderate Aortic Stenosis and Ventricular Function Deterioration

Aortic Stenosis (AS) significantly contributes to valvulo-arterial impedance in patients with heart failure and reduced ejection fraction (HFrEF), making it a relevant therapeutic target...