While the rate of stroke has decreased since the early days of transcatheter aortic valve replacement (TAVR), it remains non-negligible, reaching up to 1%-3% at 30 days. As TAVR progressively expands to low-risk populations and younger patients, identifying risk factors for patient selection and management in stroke prevention becomes crucial.
While researchers have identified predictors of stroke at 30 days such as the interaction between the calcified native valve and the device, hemodynamic instability, and patient-related factors, there is a lack of data on these predictors in the medium and long term.
The objective of this analysis, based on the OBSERVANT II study (a multicenter, observational, and prospective study), was to assess the incidence of stroke at 30 days and 6 months after TAVR, identifying predictors linked to both the procedure and the patient.
The primary endpoint (PEP) was the incidence of stroke after TAVR at 30 days and 6 months.
The analysis included 2753 patients, with an average age of 81 years and a predominance of female subjects. The EUROSCORE II was higher than 4% in 61% of cases. Transfemoral access was used in most procedures. The most common device was EVOLUT R/PRO (53%), followed by SAPIEN 3 (27%), ACURATE Neo (10%), and PORTICO (8%). There were no significant differences in the incidence of stroke among the various devices.
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Regarding results, the incidence of stroke was 1.3% at 30 days and 2.4% at 6 months. In relation to predictors, logistic regression analysis revealed that predilation (odds ratio [OR]: 2.28; 95% confidence interval [CI]: 1.12–4.65, p = 0.023), diabetes (OR: 3.10, 95% CI: 1.56–6.18, p = 0.001), and ejection fraction < 50% (OR: 2.15, 95% CI: 1.04–4.47, p = 0.04) were independent predictors of stroke at 30 days. The use of dual antiplatelet therapy (DAPT) and anticoagulation was inversely associated with the risk of stroke.
Regarding predictors of stroke at 6 months, diabetes (hazard ratio [HR]: 2.07; 95% CI: 1.25–3.42, p = 0.004), neurological dysfunction (HR: 3.92, 95% CI: 1.52–10, p = 0.004), and critical condition (HR: 3.05, 95% CI: 1.21–7.72, p = 0.018) were independent predictors. The bicuspid valve also proved to be a significant predictor of stroke at 6 months, with a wide confidence interval (HR: 4.75, 95% CI: 1.44–15.7, p = 0.011). The use of single/dual antiplatelet therapy and anticoagulation was also inversely associated with the risk of stroke at 6 months.
Conclusion
In conclusion, the stroke rate after TAVR is generally low and has decreased since the inception of such a strategy. This study revealed that most predictors of stroke at 30 days and 6 months are related to patient factors, which could contribute to improving risk stratification before the procedure.
Dr. Andrés Rodríguez.
Member of the Editorial Board of SOLACI.org.
Original Title: Incidence and predictors of 30‐day and 6‐month stroke after TAVR: Insights from the multicenter OBSERVANT II study.
Reference: Riccardo Gorla MD, PhD et al Catheter Cardiovasc Interv. 2023;1–10.
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