Predictors, Outcomes and Prevention of Stroke after Transcatheter Aortic Valve Replacement

Background— Every year more than 60,000 valve replacements are performed, and aortic valve replacement
is the most common intracardiac procedure performed in the United States. Stroke is one of the most concerning
complication of aortic valve replacement associated with increased mortality.
Methods— We performed a narrative literature review, enhanced by hand-search of the reference lists of included
articles and relevant reviews.
Results— Intraprocedural embolic events are most common etiology for ischemic stroke associated with both
surgical aortic valve replacement and transcatheter aortic valve replacement. Acute and subacute strokes after tran
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scatheter aortic valve replacement have been reported in 3% to 9% of patients, with majority of them occurring within
first month. Post-procedural stroke is associated with increased mortality after both surgical and transcatheter aortic
valve replacement. Predictors of stroke include female gender, diabetes mellitus, calcification of ascending aorta,
left ventricular ejection fraction <40%, acute kidney injury, peripheral vascular disease, previous stroke, walking <
300 meters during 6-minute walk test, concurrent carotid stenosis, and emergency department admission. Transfem
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oral transcatheter aortic valve replacement is the preferred approach and nonfemoral access is only used in 6% to
10% of patients in the United States. Transapical access seems to have rates of stroke comparable with transfemoral
approach. On contrary, studies reporting subclavian/transaxillary access have yield contradictory results regarding
stroke risk. The use of cerebral protection devices, such as Food and Drug Administration approved Sentinel device
during transcatheter aortic valve replacement, may be associated with a lower rate of stroke at 30-days.
Conclusions— The rate and predictors of ischemic stroke associated with both surgical and transcatheter aortic
valve replacement need to be recognized. The use of cerebral protection devices during transcatheter aortic valve
replacement maybe associated with a lower 30-day stroke rate with transcatheter aortic valve replacement procedures.
Keywords— Transcatheter aortic valve replacement, surgical aortic valve replacement, stroke, cerebrovascular
event, cerebral protection devices, mortality.