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PCR London Valves

Clinical Articles, Lead Article

Reducing stroke risk with TAVI

Studies have indicated that the first 30 days following transcatheter aortic valve implantation (TAVI) are associated with an increased risk of stroke or transient ischaemic attack compared with surgical aortic valve replacement in high-risk patients. While this risk lessens over time, with no difference in the rate of stroke between surgery and TAVI observed at two years, reducing the risk of stroke during TAVI remains an important issue, according to Nicolas Van Mieghem (Department of Interventional Cardiology Thoraxcenter, Erasmus Medical Center, Rotterdam, the Netherlands).1

Speaking at the PCR London Valves meeting recently, Dr Van Mieghem said that the risk of stroke is greatest during the first 24–48 hours after a TAVI procedure and is thereafter determined by the presence of new-onset atrial fibrillation.

He said: “The incidence of new-onset of atrial fibrillation after TAVI is approximately 30%. The presence of atrial fibrillation justifies the use of anticoagulation therapy in elderly patients.” He added that the use of new anticoagulants (i.e. dabigatran, rivaroxaban, or apixaban) in patients who have undergone TAVI is an “open question,” but his opinion is that they do have a role.

Mieghem Headshot

Dr Nicolas Van Mieghem (Erasmus Medical Center, Rotterdam, the Netherlands)

Dr Van Mieghem believes that the “major hurdle” in reducing the risk of stroke after TAVI is the aortic root. He explained: “The need to cross the aortic root is an issue that needs to be addressed with all approaches, regardless of the access site.”

He said that reducing the instrumentation in the aortic root can help to reduce the risk of stroke. This includes avoiding balloon pre- or post-dilation and keeping manipulations to a minimum (to avoid valve embolisation and dislodgement). He added that optimising perioperative anticoagulation is also important.

Embolic protection devices (which were also a focus of the meeting) can also be used to prevent stroke after TAVI. A study, published in Circulation, by Van Mieghem et al, reviewed the use of a dual filter-based embolic protection device in 40 patients undergoing TAVI. They found that in 75% of patients, the device captured embolic debris that was travelling to the brain. Dr Van Mieghem commented: “Furthermore, in more than half of patients, the debris was tissue related.”

“Embolic protection devices do have a role in preventing stroke in patients undergoing TAVI, particularly in addressing subclinical new brain lesions that may predispose patients to neurocognitive deficits in the long run,” he concluded.

References

1. Van Mieghem N. Managing the risk of stroke with TAVI. Session insight.  PCR London Valves 2013 programme.

Published on: September 18, 2013

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ENDORSED BY

  • ArrhythmiaAlliance
  • Stars
  • Anticoagulation Europe
  • Atrial Fibrillation Association
 

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