Abstract
Transcatheter aortic valve implantation (TAVI) is now a widely adopted option for many inoperable and high risk patients with severe aortic valve stenosis, and clinical trials continue to show great benefit with regards to mortality and major cardiovascular endpoints. As the technology continues to expand and possibly grow to include intermediate and low risk populations, investigators have remained focused on efforts to reduce the risk of peri-procedural complications, of which neurologic events remain some of the most feared. Fortunately, contemporary studies have shown a significant decline in the risk of stroke with TAVI as compared to early clinical trials, and no difference when compared to surgical aortic valve replacement in the most recent trials. This review will focus on current methods for diagnosing, defining, and quantifying the effect of stroke after TAVI, explore the evidence with regards to stroke risk in various populations undergoing these procedures, discuss possible mechanisms for both early and late neurologic events after TAVI, and discuss strategies for both pharmacologic and device based embolic protection during these procedures.
Highlights
Transcatheter aortic valve implantation (TAVI) provides a significant mortality benefit for patients with severe aortic stenosis who are at prohibitive surgical risk [1,2]
Clinical trials suggested a higher incidence of neurologic events in patients undergoing TAVI as compared to surgical AVR and/or non-operative control groups, but more recent studies have shown a significant decrease in the incidence of stroke and TIA in these populations
Embolic protection strategies: As most events are thought to be embolic in nature, the utilization of filters and embolic deflection devices during TAVI has become an exciting strategy to potentially reduce the incidence of peri-procedural stroke [35]
Summary
Transcatheter aortic valve implantation (TAVI) provides a significant mortality benefit for patients with severe aortic stenosis who are at prohibitive surgical risk [1,2]. It is an effective alternative to surgical aortic valve replacement (SAVR) for patients at high surgical risk, with some studies showing superiority [3,4]. It continues to be studied in intermediate risk populations and the results from large clinical trials are eagerly awaited. Clinical trials suggested a higher incidence of neurologic events in patients undergoing TAVI as compared to surgical AVR and/or non-operative control groups, but more recent studies have shown a significant decrease in the incidence of stroke and TIA in these populations. In this review we will explore the data regarding the diagnosis, definition, and incidence of these events, discuss the possible mechanisms for neurologic events that occur both during and after TAVI, and focus on pharmacologic and procedural based strategies to reduce strokes associated with TAVI including the utilization of intra-procedural, embolic protection devices
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