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Stroke following transcatheter aortic valve implantation. Is neuroprotection justified?

Dąbrowski M, Witkowski A - Postepy Kardiol Interwencyjnej (2013)

Bottom Line: In the last 10 years dynamic development of transcatheter aortic valve implantation (TAVI) has been observed as an alternative to SAVR in patients with AS and high risk for surgery.The Claret System is designed to filter cerebral blood flow within the ostia of the brachiocephalic trunk, as well as in the left common carotid artery.Randomized clinical data have demonstrated that TAVI is associated with more neurological events compared to SAVR.

View Article: PubMed Central - PubMed

Affiliation: Department of Interventional Cardiology and Angiology, Institute of Cardiology, Warsaw, Poland.

ABSTRACT
Degenerative aortic stenosis (AS) is the most frequent type of valvular heart disease. In patients with symptomatic AS surgical aortic valve replacement (SAVR) is a recommended treatment strategy. Due to a high risk of perioperative mortality, up to 30% of patients with AS are considered not suitable for SAVR. In the last 10 years dynamic development of transcatheter aortic valve implantation (TAVI) has been observed as an alternative to SAVR in patients with AS and high risk for surgery. In the two randomized trials published so far and numerous registries, stroke and transient ischemic attack still remain serious periprocedural complications after TAVI. Because the majority of these episodes are driven by microembolization during the procedure, different neuroprotection devices were developed and clinically tested. Embrella and SMT are deflector devices, using a microporous membrane mounted on a nitinol frame, designed to cover the ostia of the brachiocephalic trunk and the left carotid artery. The Claret System is designed to filter cerebral blood flow within the ostia of the brachiocephalic trunk, as well as in the left common carotid artery. Randomized clinical data have demonstrated that TAVI is associated with more neurological events compared to SAVR. However, to date the efficacy of the neuroprotection systems has not been assessed in randomized trials. Before we know the results of such trials, the use of the devices should be limited to patients at high risk of neurological complications, such as patients with previous stroke, massive calcification on aortic leaflets, annulus and porcelain aorta.

No MeSH data available.


Related in: MedlinePlus

Representative examples of TAVI-induced liberation of debris. Representative specimens were retrieved within the proximal (right, brachiocephalic filter) and distal filters (left, carotid filter) verifying successful bilateral reduction of embolic burden with the Claret CE Pro™ system during TAVI
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Figure 0005: Representative examples of TAVI-induced liberation of debris. Representative specimens were retrieved within the proximal (right, brachiocephalic filter) and distal filters (left, carotid filter) verifying successful bilateral reduction of embolic burden with the Claret CE Pro™ system during TAVI

Mentions: At the Institute of Cardiology in Warsaw we performed the first two Polish TAVI procedures using the Claret Filter System. In 1 patient it was not possible to fully expand the distal filter on the left common carotid artery because of unusual anatomy (bovine arch). In both filters embolic material was found after the successful completion of TAVI (Figure 5) and in DW-MRI there were no new acute cerebral defects. A second Claret device had to be used in this case to achieve full cerebral protection. In the second patient we observed minor stroke with partial amaurosis in the right eye. In DW-MRI a new acute ischemic focus was found in the territory corresponding to the left vertebral artery (Figure 6).


Stroke following transcatheter aortic valve implantation. Is neuroprotection justified?

Dąbrowski M, Witkowski A - Postepy Kardiol Interwencyjnej (2013)

Representative examples of TAVI-induced liberation of debris. Representative specimens were retrieved within the proximal (right, brachiocephalic filter) and distal filters (left, carotid filter) verifying successful bilateral reduction of embolic burden with the Claret CE Pro™ system during TAVI
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC3927112&req=5

Figure 0005: Representative examples of TAVI-induced liberation of debris. Representative specimens were retrieved within the proximal (right, brachiocephalic filter) and distal filters (left, carotid filter) verifying successful bilateral reduction of embolic burden with the Claret CE Pro™ system during TAVI
Mentions: At the Institute of Cardiology in Warsaw we performed the first two Polish TAVI procedures using the Claret Filter System. In 1 patient it was not possible to fully expand the distal filter on the left common carotid artery because of unusual anatomy (bovine arch). In both filters embolic material was found after the successful completion of TAVI (Figure 5) and in DW-MRI there were no new acute cerebral defects. A second Claret device had to be used in this case to achieve full cerebral protection. In the second patient we observed minor stroke with partial amaurosis in the right eye. In DW-MRI a new acute ischemic focus was found in the territory corresponding to the left vertebral artery (Figure 6).

Bottom Line: In the last 10 years dynamic development of transcatheter aortic valve implantation (TAVI) has been observed as an alternative to SAVR in patients with AS and high risk for surgery.The Claret System is designed to filter cerebral blood flow within the ostia of the brachiocephalic trunk, as well as in the left common carotid artery.Randomized clinical data have demonstrated that TAVI is associated with more neurological events compared to SAVR.

View Article: PubMed Central - PubMed

Affiliation: Department of Interventional Cardiology and Angiology, Institute of Cardiology, Warsaw, Poland.

ABSTRACT
Degenerative aortic stenosis (AS) is the most frequent type of valvular heart disease. In patients with symptomatic AS surgical aortic valve replacement (SAVR) is a recommended treatment strategy. Due to a high risk of perioperative mortality, up to 30% of patients with AS are considered not suitable for SAVR. In the last 10 years dynamic development of transcatheter aortic valve implantation (TAVI) has been observed as an alternative to SAVR in patients with AS and high risk for surgery. In the two randomized trials published so far and numerous registries, stroke and transient ischemic attack still remain serious periprocedural complications after TAVI. Because the majority of these episodes are driven by microembolization during the procedure, different neuroprotection devices were developed and clinically tested. Embrella and SMT are deflector devices, using a microporous membrane mounted on a nitinol frame, designed to cover the ostia of the brachiocephalic trunk and the left carotid artery. The Claret System is designed to filter cerebral blood flow within the ostia of the brachiocephalic trunk, as well as in the left common carotid artery. Randomized clinical data have demonstrated that TAVI is associated with more neurological events compared to SAVR. However, to date the efficacy of the neuroprotection systems has not been assessed in randomized trials. Before we know the results of such trials, the use of the devices should be limited to patients at high risk of neurological complications, such as patients with previous stroke, massive calcification on aortic leaflets, annulus and porcelain aorta.

No MeSH data available.


Related in: MedlinePlus