Response to Letters Regarding Article, “Cerebral Embolization During Transcatheter Aortic Valve Implantation: A Transcranial Doppler Study”

Abstract

The importance of cerebral embolization as the main cause of periprocedural stroke during transcatheter aortic valve implantation has recently been demonstrated. Erdoes and colleagues1 have reported high-intensity transient signals as surrogates for microemboli during all phases of the procedure, predominantly during valve implantation, with no difference between transfemoral and transapical access and slightly more microemboli with the self-expandable than with the balloon-expandable stent valve. We not only confirmed their findings but extended them to highlight the calcified aortic valve as the main source of emboli and mean transaortic gradient at baseline, reflecting aortic stenosis severity, as an independent predictor for the frequency of high-intensity transient signals.2 We agree that a “minimal-touch technique”1,3 with modest manipulation of the aortic arch and, more important, the aortic valve is key to minimizing periprocedural embolism and stroke. We also agree that a minimal-touch principle should be extended to the brachiocephalic and carotid arteries, which are regularly atherosclerotic in the elderly …