Successful management of cerebral embolism during TAVR

Abstract

An 89-year-old woman underwent transfemoral aortic valve replacement (TAVR) for treatment of severe symptomatic aortic stenosis as recommended by the institutional heart team (transvalvular gradient max 71 mmHg/mean 55 mmHg). Aortic annulus size as determined by computed tomography (CT) was 19 mm with moderate calcifications. Accordingly, a 23 mm Edwards Sapien XT valve (Edwards Lifesciences) was selected. The patient was preloaded with 500 mg Aspirin and 100 IE/kg of unfractionated heparin was given during the procedure. After successful implantation of the valve under conscious sedation, the patient presented with right sided hemiplegia and aphasia. The patient was immediately transferred from the cath lab to cerebral CT angiography which revealed complete occlusion of the M1 branch of the left middle cerebral artery (ACM). After transfer to the neuroradiology intervention room, intubation, and reaccess to the left femoral artery, a catheter was placed in the left carotid artery confirming the occlusion and sufficient collateralization (Fig. 1a). Contrast injection via a microcatheter after passage of the occlusion with a microwire demonstrated correct positioning (Fig. 1b). Subsequently, a Solitaire 4 9 20 mm Stent Retriever (Covidien) was placed in the occluded segment and released for 5 min. Contrast injection assessed filling of the stent retriever (Fig. 2a). Subsequently, the device was retrieved and substantial thrombotic material was attained (Fig. 3). The final angiogram revealed complete restoration of flow (Fig. 2b). The patient was extubated after the procedure and mobilized on the next day without any residual neurological pathology. Cerebral embolization is a critical complication of TAVR [1]. Successful neurovascular rescue was recently described in a patient with stroke after TAVR performed in general anesthesia [2]. Conduction of TAVR under conscious sedation, however, allows for rapid assessment of neurological symptoms during and after the procedure. Timely diagnosis of cerebral ischemia facilitates immediate and full restoration of cerebral flow.