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Cerebral microembolization likely in all cases of TAVR
Cerebral microembolization, reflected as high-intensity transient signals, was detected in all patients who underwent transcatheter aortic valve replacement, mostly during manipulation of the calcified native valve while positioning and implanting the transcatheter valves.
Despite this, study investigators reported that there was no increase in neurological deficits or acutely impaired neurocognitive function.
In all, the study included 83 high-risk patients with severe symptomatic aortic valve stenosis who underwent TAVR at a single site in Germany using one of three devices approved in Europe. Of these patients, 32 received transfemoral implantation of the CoreValve (Medtronic; MCVTF), 26 received transfemoral implantation of the Sapien valve (Edwards Lifesciences; ESTF), and 25 received transapical implantation of the Sapien valve (ESTA). Serial transcranial Doppler exams before, during and 3 months after the procedure were used to identify high-intensity transient signals, which was used as a surrogate for microembolization.
Transcranial Doppler detected high-intensity transient signals in all patients during the procedures, mostly while manipulating the calcified aortic valve while stent valves were being positioned and implanted. The balloon-expandable ES prosthesis caused significantly more high-intensity transient signals during positioning (ESTF=259.9; 95% CI, 184.8-334.9; ESTA=206.1; 95% CI, 162.5-249.7; MCVTF=78.5; 95% CI, 25.3-131.6).
However, the self-expandable MCV prosthesis caused significantly more high-intensity transient signals during implantation (MCVTF=397.1; 95% CI, 302.1-492.2; ESTF=88.2; 95% CI, 70.2-106.3; ESTA=110.7; 95% CI, 82-139.3).
There were no significant differences between transfemoral and transapical TAVR or between the MCV and ES prostheses, researchers reported. No high-intensity transient signals were identified at baseline or 3-month follow-up. There was one major procedural stroke that resulted in death and one minor procedural stroke with full recovery at 3-month follow-up in the MCV group.
“The high frequency of lesions on neuroimaging and [high-intensity transient signals] in [transcranial Doppler] calls for procedural and technical developments to reduce the risk of periprocedural embolization: Less traumatic devices, avoidance of extensive manipulation of the calcified aortic valve (‘time is brain’), carotid artery compression during valve positioning and deployment, omission of preparatory balloon valvuloplasty and protection devices are currently under consideration,” the investigators wrote.
Disclosure: Drs. Kahlert and Thielmann are clinical proctors for Edwards Lifesciences and have received honoraria payments. Dr. Eggebrecht is a clinical proctor for Medtronic and has received honoraria payment.