Risk Of Cerebral Embolism Research Articles

Assessing left atrial size and pump function in ischemic stroke patients: Is cardiac MRI superior to transthoracic echocardiography?

ObjectivesCurrent guidelines recommend transthoracic echocardiography (TTE) following an ischemic stroke as the primary technique to identify cardiac abnormalities associated with an increased risk of cerebral embolism. It is unclear whether cardiac magnetic resonance imaging (cMRI), a technique shown to provide increased imaging resolution, may also enhance the cardiac assessment of ischemic stroke patients. We compared cMRI with TTE in the evaluation of Left Atrial (LA) size and pump function in a cohort of 44 patients with ischemic stroke. Materials and methodsThe biplane method was utilized to acquire LA diameters as well as area measurements in both TTE and cMRI. We calculated LA volume (LAV), LAV index (LAVI), LA Global Longitudinal Strain (GLS) and LA pump function. Results were compared using paired two sample for means t-test. Lin's concordance correlation coefficient (CCC) and Bland-Altman methods quantified the agreement of measurements obtained by TTE and cMRI. ResultsLAVI measurements by cMRI were significantly larger (34.97 v. 28.81; p = 0.001) than by TTE. The concordance correlation demonstrated only a weak agreement between LA size measured by cMRI and TTE (ρc = 0.397; p= 0.001, 95% CI 0.16 - 0.59), and the Bland-Altman plot demonstrated that LAVI measured by cMRI averaged 6.3 ml/m2 larger magnitude than those obtained by TTE. ConclusionsUsing TTE alone leads to an underestimation of LA abnormalities important in the evaluation of ischemic stroke patients. Nearly one in every five ischemic stroke patients evaluated based on the current guidelines may have a missed potential source of cardiac embolism.

Abstract 15586: Efficacy and Safety of Cerebral Embolic Protection Devices in Transcatheter Aortic-Valve Replacement: An Updated Systematic Review and Meta-Analysis of Randomized Controlled Trials

Introduction: Transcatheter aortic-valve replacement (TAVR) has emerged as a viable alternative to surgical aortic-valve replacement for high-risk patients. However, the procedure carries a significant risk of cerebral embolism. Cerebral embolic protection (CEP) devices have been proposed to mitigate this risk, yet current evidence of their efficacy remains inconsistent. Hypothesis: This study aims to comprehensively evaluate the effectiveness and safety of CEP devices during TAVR. Methods: A systematic literature search was conducted in MEDLINE, EMBASE, and Scopus up to April 2023. Randomized controlled trials (RCTs) comparing TAVR with and without CEP were included. The study assessed total lesion volume using mean difference (MD), while stroke, mortality, bleeding and vascular complications, and new magnetic resonance imaging (MRI) detected lesions were evaluated with relative risk (RR); both were analyzed via random-effects models using R software (version 4.0.3) with the metafor and meta packages. Results: The meta-analysis incorporated five RCTs involving 3,845 patients (2,070 received CEP devices, and 1,775 served as a control). The pooled analysis showed a non-significant mean difference in total lesion volume of -14.43 (95% CI: -104.97 to 76.09, P=0.75, I2=90%), indicating that CEP devices did not significantly alter the total lesion volume. In terms of other outcomes, the use of CEP devices did not significantly reduce the risk of stroke (RR 0.86, 95% CI: 0.62 to 1.22, P=0.41, I2=0%), disabling stroke (RR 0.50, 95% CI: 0.24 to 1.04, P=0.06, I2=0%), overall mortality (RR 1.35, 95% CI: 0.59 to 3.12, P=0.48, I2=0%), life-threatening or major bleeding (RR 1.09, 95% CI: 0.37 to 3.22, P=0.88, I2=19%), vascular complications (RR 1.83, 95% CI: 0.80 to 4.19, P=0.15, I2=29%), or the occurrence of new lesions seen on MRI (RR 0.99, 95% CI: 0.93 to 1.06, P=0.78, I2=17%). Conclusions: The results indicate that CEP devices during TAVR did not significantly alter important clinical outcomes, challenging the presumed benefits of these devices. Owing to the limited number of studies and short follow-up periods, further large-scale RCTs with more sophisticated designs and longer follow-ups are needed to validate these results and inform future guidelines.

Defining the Role of Anaortic Coronary Artery Bypass Grafting.

As the population ages and co-morbidities become more prevalent, the complexity of patients presenting for coronary artery bypass surgery is increasing. Cardiopulmonary bypass and aortic cross-clamping in these patients carry increased risk and, indeed, in some patients, with ascending aortic disease, the risks are prohibitive. Total-arterial anaortic coronary artery surgery is a technique that provides complete surgical coronary artery revascularization without cardiopulmonary bypass and without manipulating the ascending aorta. The technique essentially eliminates the risk of cerebral embolization of aortic atheroma and aortic injury. Anaortic techniques are an essential skillset for coronary artery surgery centers treating higher-risk patients.

Efficacy of Angioscopy for the Detection of Mobile Carotid Artery Lesions

Case presentation A 78‐year‐old man with a mobile lesion was diagnosed with thrombus using carotid ultrasonography, but the lesion was not completely resolved with dual antiplatelet and anticoagulation therapy. Direct visualization by angioscopy showed a white mobile plaque. The carotid artery was stented with a double‐layered stent, as the plaque persisted despite continuing the medical treatment and was linked to an increased risk of cerebral embolism. The plaque was attached to the arterial wall, and it subsequently disappeared. The patient recovered well and no further emboli were observed. Conclusions Angioscopy is effective for identifying lesions under direct vision. The characteristics and dynamics of plaques may be viewed via angioscopy, which aids in making treatment‐related decisions, particularly in the case of carotid artery plaques.

P295 WHEN TAVI IS THE RIGHT CHOICE

Abstract Clinical case We describe a case of a 62–y–old man, affected by hypertension, insulin–dependent diabetes mellitus, advanced liver cirrhosis. After screeing, the patient was listed for liver transplantation. On September 2022, the patient was admitted to our Emergency Room due to HF in class NYHA III. The transthoracic echocardiogram showed a severe aortic regurgitation with mobile vegetations, the largest of which is more than 10 mm on the right aortic cusp. Normal biventricular function was observed with sPAP of 45 mmHg. Thus, we concluded for post–endocarditis severe aortic regurgitation. We discussed tha case in our Department Heart Team with the concomitant presence of the Liver Team. We considered the patient at high surgical risk, mostly due to the risk of postoperative hepatic insufficiency. So, we decided for a TAVI off–label. So, we impantanted a Sapien 3 Ultra 26 mm through transfemoral access. To reduce the risk of cerebral embolization, we used Triguard 3 system, while to prevent coronary embolization we used a closed stent into the right coronary ostia, ready to be opened. The patient was discharged in the fourth postoperative day, without conduction disturbances. The postoperative echo showed normal valvular function and absence of paravalvular leakages. Conclusions Patients with advanced liver cirrhosis are at risk of organ failure following use of extracorporeal circulation. In selected patients, TAVI may be a valid alternative. The peculiarity of the specific case was due to the use of the TAVI in an off–label procedure of aortic insufficiency with the simultaneous presence of mobile vegetation at high embolic risk.

Successful Outflow Graft Stent Placement for a Malfunctioning Left Ventricular Assist Device

A 79-year-old man presented with hypertension and a 24-hour history of low flow alarms (flow <2.5 L/min) from his left ventricular assist device (LVAD, HeartMate II; Abbott Cardiovascular, Chicago, Illinois). At a 90-mm Hg pressure gradient, 90% stenosis of the 14-mm outflow graft tract was noted upon left heart catheterization, between the bend relief and aortic anastomosis. No standardized management has been established for graft stenosis because of technique-related challenges, including proximity of the LVAD motor to the wire, possible stent migration or slippage, and the risk of cerebral embolism.

Cyanosis in a Previously Well Child.

Cyanosis in a Previously Well Child.

Computational Fluid Dynamics Study of Cerebral Thromboembolism Risk in Ventricular Assist Device Patients: Effects of Pulsatility and Thrombus Origin.

This study investigates the hypothesis that by surgically manipulating the outflow graft (OG) implantation during ventricle assist device placement, it may be possible to reduce the risk of cerebral embolism. We investigate this hypothesis using a computational approach on a patient-specific basis under fully pulsatile hemodynamics with a multiscale computational fluid dynamics model incorporating a coupled Eulerian-Lagrangian scheme that effectively tracks emboli in the fluid domain. Blood is modeled as a non-Newtonian fluid based on the hematocrit level. Preliminary flow analysis shows that depending on the anastomosis angle the left ventricular assist device (LVAD) can enhance the flow to the cerebral circulation by nearly 31%. Z-test results suggest that unsteady-flow modeling ought to be an integral part of any cardiovascular simulation with residual ventricular function. Assuming unsteady-flow conditions, a shallow LVAD outflow graft anastomosis angle is the most optimal if thrombi are released from the aortic-root reducing cerebral embolization incidence to 15.5% and from the ventricle to 17%, while a more pronounced anastomosis angle becomes advantageous when particles originate from the LVAD with an embolization rate of 16.9%. Overall, computations suggest that a pronounced LVAD anastomosis angle is the better implementation. Unsteady modeling is shown to be necessary for the presence of significant antegrade aortic-root flow which induces cyclical flow patterns due to residual pulsatility. On the other hand, depending on thrombus origin and ventricular assist devices (VAD) anastomosis angle there is a strong tradeoff in embolization rates.

Cerebral Emboli Monitoring Using Transcranial Doppler Ultrasonography in Adults and Children: A Review of the Current Technology and Clinical Applications in the Perioperative and Intensive Care Setting.

Transcranial Doppler (TCD) ultrasonography is the only noninvasive bedside technology for the detection and monitoring of cerebral embolism. TCD may identify patients at risk of acute and chronic neurologic injury from gaseous or solid emboli. Importantly, a window of opportunity for intervention-to eliminate the source of the emboli and thereby prevent subsequent development of a clinical or subclinical stroke-may be identified using TCD. In this review, we discuss the application of TCD sonography in the perioperative and intensive care setting in adults and children known to be at increased risk of cerebral embolism. The major challenge for evaluation of emboli, especially in children, is the need to establish the ground truth and define true emboli identified by TCD. This requires the development and validation of a predictive TCD emboli monitoring technique so that appropriately designed clinical studies intended to identify specific modifiable factors and develop potential strategies to reduce pathologic cerebral embolic burden can be performed.

Cerebral Embolism Beyond Atrial Fibrillation: Interatrial Block

This paper is devoted to conditions that imply a risk for cerebral embolism beyond atrial fibrillation (AF). We focus on advanced interatrial block (IAB) and its relationship with stroke in elderly patients with no documented arrhythmias. Advanced IAB is manifested in the surface electrocardiogram (ECG) as a P-wave duration &gt;120 ms plus biphasic morphology (positive and negative deflection) in leads II, III, and aVF. Several data suggest that AF is not necessarily the leading cause of stroke, but rather a risk factor. In fact, a high stroke risk has been described even in the absence of AF in patients with high CHA2DS2VASc-score (Congestive Heart failure, hypertension, Age ≥75 years [doubled], Diabetes, Stroke [doubled], Vascular disease, Age 65-74 years, Sex category [female sex]). Moreover, excessive atrial ectopy and short atrial runs also increase stroke risk. Some of the previously mentioned stroke risk factors in patients without documented arrhythmias might be combined to determine thrombotic risk. That risk is particularly high in elderly patients with advanced IAB, structural heart disease, CHA2DS2-VASc score ≥3, and frequent ambient atrial arrhythmias. Systematic screening for advanced IAB in elderly patients can be performed with a simple surface ECG. Advanced IAB is a risk marker of stroke.

Recent Intraplaque Hemorrhage Is Associated with a Higher Risk of Ipsilateral Cerebral Embolism During Carotid Artery Stenting

The purpose of this study was to identify which stage of intraplaque hemorrhage (IPH) is an independent risk factor for ipsilateral new ischemic lesions (NILs) after carotid artery stenting (CAS). In 268 patients treated with CAS, the association between postoperative ipsilateral NILs on diffusion-weighted imaging (DWI) and patient demographics, intraoperative factors, and plaque characteristics on multicontrast atherosclerosis characterization sequence was retrospectively analyzed. A total of 268 patients were enrolled in the study. Ipsilateral NILs on DWI were detected in 32.8% of patients. Univariate analysis showed that the stage of IPH (along with lipid-rich necrotic core [LRNC]) (P < 0.001) in the carotid plaque, predilation (P= 0.012), stent type (P=0.002), and aortic arch ulcer (P= 0.009) were associated with postoperative ipsilateral NILs, whereas other patient-related factors (P >0.05), type of embolic protection device (P= 0.072), postdilation (P= 0.388), calcification (P= 0.140), and LRNC (without IPH) (P=0.086) were not. Multivariate logistic regression analysis showed that the acute and recent IPH (along with LRNC) (odds ratio [OR], 3.78, P= 0.011 and OR, 16.73, P < 0.001, respectively), aortic arch ulcer (OR, 2.46; P= 0.006), predilation (OR, 4.78; P= 0.015), and open cell stent (OR, 4.19; P < 0.001) were significantly associated with postoperative ipsilateral NILs on DWI. Screening for recent IPH in carotid plaques using multicontrast atherosclerosis characterization sequence may identify plaques at a higher risk for cerebral embolism during CAS.

P2756Risk of stroke subsequent to infective endocarditis: a nationwide study

Abstract Background Patients with infective endocarditis (IE) are at high risk of cerebral embolization, however little is known about the risk of stroke subsequent to IE in patients with stroke during IE admission. Purpose To investigate the risk of stroke after discharge of IE in patients with stroke during IE admission compared with patients without stroke during IE admission. Methods Using Danish nationwide registries we identified non-surgically treated patients with IE discharged alive, in the period 1996–2016. The study population was grouped in 1) patients with stroke during IE admission and 2) patients without stroke during IE admission. Crude cumulative risk of stoke were calculated using the Aalen-Johansen estimator accounting for death as a competing risk. Multivariable adjusted Cox proportional hazard analysis was used to compare the associated risk of stroke between groups. We identified differentials in the associated risk of stroke during follow-up between groups (p=0.006 for interaction with time), and follow-up was split into 0–1 year and 1–5 years time periods. Results We identified 4,284 patients with IE, 239 patients (5.6%) with stroke during IE admission (median age: 71.9 years, 58.2% males), and 4,045 patients (94.4%) without stroke during IE admission (median age 69.7 years, 64.8% males). The crude cumulative risk of stroke within 1 year of follow-up is shown in Figure Panel A, and with 1 to 5 years of follow-up in Figure Panel B. In multivariable adjusted analyses, the associated risk of stroke was higher in patients with stroke during IE admission within a follow-up period of 1 year, HR 3.21 (95% CI: 1.66–6.20) compared with patients without stroke during IE admission. From 1 to 5 years of follow-up, we identified no difference in the associated risk of stroke between groups, HR 0.91 (95% CI: 0.33–2.50). Cumulative incidence of stroke Conclusion Non-surgically treated patients with IE who had a stroke during IE admission were at significantly higher associated risk of subsequent stroke – although not significant beyond 1 year after discharge from IE. These findings underline the need for identification of causes and mechanisms of recurrent strokes after IE to develop preventive means.

Associations between carotid intraplaque hemorrhage and new ipsilateral ischemic lesions after carotid artery stenting: a quantitative study with conventional multi-contrast MRI.

The risk of cerebral embolism after CAS in patients with carotid IPH is still controversial. This study was to further investigate the relationship between IPH and new ipsilateral ischemic lesion (NIIL) after CAS, and to perform a volumetric analysis of IPH for predicting the risk of NIIL following CAS. One hundred and seventeen patients with carotid stenosis undergoing CAS were prospectively enrolled. Preprocedural multi-contrast carotid MRI was performed. NIIL was evaluated by brain DWI before and after CAS. IPH volume, wall volume at the plaque (WVplaque) and relative IPH volume were calculated. Associations between IPH and postprocedural NIIL were studied. NIILs were shown in 52 patients. IPH were identified in 53 patients. NIILs were found more frequently in IPH-positive (33/53, 62.3%) than in IPH-negative patients (19/64, 29.7%, p < 0.001). There was no significant difference of WVplaque between NIIL-positive and NIIL-negative patients (1166.6 ± 432.0 mm3 vs 1124.6 ± 410.4mm3, p = 0.592). The IPH volume from NIIL-positive group was significantly larger than that of NIIL-negative group (252.8 ± 264.9 mm3 vs 59.3 ± 131.1mm3, p < 0.001), with also higher relative IPH volume (20.4 ± 19.1% vs 5.7 ± 12.2%, p < 0.001). ROC curve showed that 183.45mm3 of the IPH volume was the most reliable cutoff value for predicting NIIL with a specificity of 92.3% and a positive predictive value of 86.1%. Larger IPH volume is associated with increased risk of NIIL after CAS procedure. Quantification of IPH volume may be useful for predicting cerebral ischemic events after CAS.

Invited commentary

Mirza and colleagues present outcomes of upper extremity access (UEA) for complex aortic repair of thoracoabdominal aortic aneurysms (TAAAs).1Mirza A.K. Oderich G.S. Sandri G.A. Tenorio E.R. Davila V.J. Kärkkäinen J.M. et al.Outcomes of upper extremity access during fenestrated-branched endovascular aortic repair.J Vasc Surg. 2019; 69: 635-644Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar To date, this is by far the largest retrospective study on the topic, and the authors are to be congratulated for their results and this important effort to cast some light on a frequently neglected topic. Except for a few reports, UEA for complex aortic repair has rarely been focused on and can be controversially discussed with a diversity of approaches.2Fiorucci B. Kölbel T. Rohlffs F. Heidemann F. Debus S.E. Tsilimparis N. Right brachial access is safe for branched endovascular aneurysm repair in complex aortic disease.J Vasc Surg. 2017; 66: 360-366Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar, 3Knowles M. Nation D.A. Timaran D.E. Gomez L.F. Baig M.S. Valentine R.J. et al.Upper extremity access for fenestrated endovascular aortic aneurysm repair is not associated with increased morbidity.J Vasc Surg. 2015; 61: 80-87Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar The complication rate for UEA in the presented large study from a center of excellence is exceptionally low. However, the majority are strokes, and real-world data would presumably show a significantly higher rate of serious neurologic complications. Operator-reported neurologic outcomes without examination by a neurologist and diffusion-weighted magnetic resonance imaging have a tendency to underestimate the issue. Therefore, reported outcomes, as the authors mention, do not take into account silent brain injury, which is a frequent magnetic resonance finding in thoracic endovascular aortic repair and a growing concern because of induced neurocognitive decline.4Perera A.H. Rudarakanchana N. Monzon L. Bicknell C.D. Modarai B. Kirmi O. et al.Cerebral embolization, silent cerebral infarction and neurocognitive decline after thoracic endovascular aortic repair.Br J Surg. 2018; 105: 366-378Crossref PubMed Scopus (39) Google Scholar The superb illustrations in the article provide excellent visualization of the authors' preferred repair technique for dissected brachial arteries using xenogenic material in one of eight patients with UEA. Whereas the additional time required for UEA closure and patch angioplasty may prolong some of the procedures, reduced catheterization times for the target vessels seem to justify the effort. The absence of secondary procedures needed is an impressive result supporting the group's strategy of open UEA and a low threshold for patch angioplasty. In a significant proportion of complex endovascular repairs, UEA is optional, namely, when solely fenestrations are used to connect target vessels to the main graft (fenestrated endovascular aneurysm repair). Fenestrations can be connected from femoral access, although UEA may provide advantages when target vessels are caudally oriented. Differences in utilization of UEA are mostly due to tradition and surgical teaching. Mirza et al now give us valid information at what cost this frequently used optional step comes in endovascular TAAA repair. For endografts with directional branches (branched endovascular aneurysm repair), such as the t-Branch (Cook Medical, Bloomington, Ind), UEA has been judged unavoidable, and discussions have focused on the preferred side of UEA.1Mirza A.K. Oderich G.S. Sandri G.A. Tenorio E.R. Davila V.J. Kärkkäinen J.M. et al.Outcomes of upper extremity access during fenestrated-branched endovascular aortic repair.J Vasc Surg. 2019; 69: 635-644Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar, 2Fiorucci B. Kölbel T. Rohlffs F. Heidemann F. Debus S.E. Tsilimparis N. Right brachial access is safe for branched endovascular aneurysm repair in complex aortic disease.J Vasc Surg. 2017; 66: 360-366Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar However, recent experience has demonstrated that with the use of steerable sheaths, even four-branched repairs in challenging anatomy of TAAA could be performed from femoral access alone (Fig). Whereas some operators prefer left-sided UEA with the argument of reduced manipulation in the aortic arch and assumed reduced stroke risk, other operators prefer right-sided UEA because of the assumed better workflow and lower radiation dose. The authors conclude that left-sided UEA is associated with a lower stroke rate in their study but acknowledge a significant selection bias and describe a trend in their practice toward right-sided UEA for better workflow and lower radiation dose. Convincing evidence about the better access side is still lacking, and the authors' conclusion should be taken with caution as data do not support a recommendation for left-sided access in general. Outcomes of upper extremity access during fenestrated-branched endovascular aortic repairJournal of Vascular SurgeryVol. 69Issue 3PreviewUpper extremity (UE) access is frequently used during fenestrated-branched endovascular aortic repair (F-BEVAR) to facilitate catheterization of downgoing vessels. Limitations include risk of cerebral embolization and of UE arterial or peripheral nerve injury. The aim of this study was to assess outcomes of F-BEVAR using UE access. Full-Text PDF Open Archive

Cardioembolic ischemic stroke as the initial presenting complaint of a patient with acute infective endocarditis and acquired immunodeficiency syndrome

Human immunodeficiency virus (HIV) infection is an independent predictor of ischemic stroke, especially in the younger age group. Approximately 1%–5% of HIV/acquired immunodeficiency syndrome patients develop stroke. A 16-year-old male presented with a decreased level of consciousness and a history of right-sided hemiparesis, fever, cough, and dyspnea. The patient was an intravenous drug user (IVDU). Examination revealed the following: blood pressure: 130/70 mmHg, heart rate: 124×/min, temperature 38.5°C, and respiratory rate: 26×/min. Electrocardiographic findings revealed the following: sinus tachycardia: 124×/min, right-axis deviation, incomplete right bundle branch block, and right ventricular hypertrophy. Laboratory findings were as follows: microcytic hypochromic anemia (7.33 g/dL), leukocytosis (32.2 × 10^3/μL) with shift to the left, hyponatremia (122 mmol/L), HIV was positive, and chest X-ray showed pneumonia. Echocardiography showed vegetation in the posterior mitral leaflet, mitral regurgitation, and tricuspid regurgitation with an intact interatrial septum. Computed tomography scan revealed ischemic stroke of the left parieto-occipital lobe. HIV-infected individuals are at 1.5 times increased risk of stroke compared to those without. This case involves an IVDU and a HIV-positive young male presenting with large ischemic stroke in large-vessel territory, suggestive of embolic origin. A part of vegetation on the left side of the heart of this patient dislodged and caused a cerebrovascular accident. There was also unconfirmed suspicion of pulmonary embolism from the right side of the heart. Empiric antibiotics should be started before tailoring to the result of blood culture. Endocarditis conveys a significant risk of cerebral embolism resulting in ischemic stroke and a potentially dismal prognosis.

A case of multiple cerebral embolism caused by calcified amorphous tumor incidentally found by central retinal artery occlusion: a case report

A 64-year-old man presented to our hospital with visual loss on the left eye due to central retinal artery occlusion diagnosed by another ophthalmological hospital. Magnetic resonance imaging revealed small multiple cerebral infarctions on bilateral hemisphere. Transesophageal echocardiography was performed, which revealed a mass lesion like a tumor with calcification on the mitral valve. We suspected that a mass lesion is calcified amorphous tumor (CAT). Surgical resection of the mass lesion was performed, and it was diagnosed CAT by pathological examination. CAT is considered as high risk of cerebral embolism, surgical treatment should be considered as early as possible.

Outcomes of upper extremity access during fenestrated-branched endovascular aortic repair

ObjectiveUpper extremity (UE) access is frequently used during fenestrated-branched endovascular aortic repair (F-BEVAR) to facilitate catheterization of downgoing vessels. Limitations include risk of cerebral embolization and of UE arterial or peripheral nerve injury. The aim of this study was to assess outcomes of F-BEVAR using UE access. MethodsWe reviewed the clinical data of 334 consecutive patients (74% males; mean age 75 ± 8 years) treated by F-BEVAR for thoracoabdominal aortic aneurysms or pararenal aortic aneurysms between 2007 and 2016. Patients who underwent F-BEVAR with an UE approach for catheterization of the renal and/or mesenteric arteries were included in the study. End points were technical success, mortality, and a composite of access-related complications including cerebral embolization (stroke/transient ischemic attack), peripheral nerve injury, and axillary-brachial arterial complications requiring intervention. ResultsThere were 243 patients (73%) treated by F-BEVAR with UE access, including 147 patients (60%) with thoracoabdominal aortic aneurysms and 96 patients (40%) with pararenal aortic aneurysms. A total of 878 renal–mesenteric arteries were incorporated by fenestrations or branches with a mean of 3.6 ± 0.8 vessels per patient. All patients had surgical exposure of the brachial artery. The left side was selected in 228 (94%) and the right side in 15 (6%). The technical success of target vessel incorporation was achieved in 99% of patients (870 of 878). Arterial closure was performed using primary repair in 213 patients (88%) or bovine patch angioplasty in 29 (12%). Patch closure was required in 13% of patients (21 of 159) treated by 10- to 12F sheaths and 8% (7 of 83) of those who had 7- to 8F sheaths (P = .19). There were six deaths (2.5%) at 30 days or within the hospital stay, none owing to access-related complications. Major access-related complication occurred in eight patients (3%), with no difference between the 10- to 12F (6 of 159 [4%]) or 7- to 8F sheaths (2 of 83 [2%]; P = .45). Two patients (1%) had transient median nerve neuropraxia, which resolved within 1 year. One patient (0.5%) required surgical evacuation of an access site hematoma. There were no UE arterial pseudoaneurysms, occlusions, or distal embolizations. Five patients (2%) had strokes (three minor, two major), occurring more frequently with right side (2 of 15 [13%]) as compared with left-sided access (3 of 228 [1%]; P = .03). After a mean follow-up of 38 ± 15 months, there were no other access-related complications or reinterventions. ConclusionsUE arterial access with surgical exposure was associated with a low rate of complications in patients treated with F-BEVAR. Closure with patch angioplasty is frequently needed, but there were no arterial occlusions, pseudoaneurysms, or distal embolizations requiring secondary procedures.

TCT-514 Balloon-expandable Sapien 3 29mm versus self-expandable Evolut R 34mm in TAVR patients with a large annulus: Is there a difference in performance and risk of cerebral embolization?

TCT-514 Balloon-expandable Sapien 3 29mm versus self-expandable Evolut R 34mm in TAVR patients with a large annulus: Is there a difference in performance and risk of cerebral embolization?

Antithrombotic Therapy After TAVR.

Transvascular Aortic Valve Replacement (TAVR) has emerged as a treatment option in patients with severe aortic stenosis who are inoperable and has recently been evaluated in patients with intermediate surgical risk. The number of procedures is increasing worldwide in parallel with the demographic changes in industrial countries. The risk for cerebral embolism is of main concern and represents a major determinant for prognosis and quality of live after TAVR. The empiric antithrombotic therapy consists of Dual Antiplatelet Therapy (DAPT); However the risk-benefit of this approach is lacking evidence from randomized, placebo-controlled trials regarding choice and duration of antithrombotic treatment. Although anticoagulation is generally not recommended in patients with aortic bioprosthesis without atrial fibrillation, there is current uncertainty whether combination of antiplatelet and anticoagulant therapy or anticoagulation alone might represent a more favorable antithrombotic regimen compared to the current empiric standard of DAPT. In addition, so far undetected atrial fibrillation is highly prevalent in the elderly population undergoing TAVR. In particular, the favorable safety profile of Non-Vitamin K Oral Anticoagulants (NOAC) offers an attractive option. A number of trials are currently underway to investigate the benefit of NOAC in patients with and without atrial fibrillation undergoing TAVR. The present article reviews the available evidence concerning stroke risk in TAVR patients and the current and future role of antithrombotic therapy during and after the procedure.

Cerebral Protection During Catheter Ablation of Ventricular Tachycardia in Patients With Ischemic Heart Disease.

BackgroundCatheter ablation of ventricular tachycardia (VT) is associated with the risk of cerebral embolism. The origin of periprocedural brain embolism in the setting of VT ablation is often unknown and strategies to avoid it are sparse. The aim of this study was to assess the safety and feasibility of an endovascular 2‐filter‐based cerebral protection system (CPS) in left ventricular VT ablation procedures in patients with ischemic heart disease. Furthermore, histopathological correlates of periprocedural embolization were investigated.Methods and ResultsIn this pilot study, 11 patients with ischemic heart disease and sustained VT underwent left ventricular catheter ablation under CPS surveillance. The placement of the CPS was conducted before the ablation procedure via the right radial artery. The VT ablation procedure was performed via a combined transaortic and transseptal approach. All VTs were successfully ablated. Placement and retrieval of the CPS was successful and safe in all cases. No periprocedural complications related to the CPS were observed and no periprocedural transient ischemic attack or stroke occurred. Debris captured by the CPS was detected in all patients. Histology revealed that acute thrombus was the most common type of debris (91%), followed by arterial wall tissue (73%) and foreign material (55%). Less frequently found were myocardium (27%), calcification (9%), necrotic core (9%), and valve tissue (9%).ConclusionsCerebral protection during VT ablation seems to be safe and feasible. Ablation procedures of VT are associated with embolization of embolic debris, which was found in every patient.