Embolic Protection Devices for Transcatheter Aortic Valve Implantation

Abstract

Stroke represents the most feared complication of transcatheter aortic valve implantation (TAVI). Although device innovation, operator experience, and better patient selection have been associated with a progressive reduction of stroke rates, its occurrence has a relevant impact on morbidity and mortality after TAVI. Embolization of material during manipulation of catheters, wires, and devices within the aortic arch is the main mechanism of periprocedural thromboembolic cerebrovascular events (CVE). In order to prevent this phenomenon, several cerebral embolic protection devices (EPDs) have been studied in patients undergoing TAVI. These devices are intended to deflect or filter emboli and protect cerebral circulation. A multitude of studies showed the safety and feasibility of their use. The rationale for their use is further supported by the observation that debris can be found in up to 99% of patients, at the end of the procedure. However, although cerebral protection has been associated with a reduction of silent cerebral ischemic lesions identified by diffusion-weighted magnetic resonance imaging (DW-MRI), their impact on stroke risk and neurocognitive status after TAVI is still not clear. Intrinsic limitations of studies so far performed as well as the lack of standardization for definition of neurological endpoints challenge the interpretation of currently available evidence, and further studies are needed to define the role of EPDs in TAVI populations.