Stroke after TAVR: New research helps cardiologists detect early warning signs
Patient-related factors such as diabetes, neurological conditions or a left ventricle ejection fraction (LVEF) less than 50% are all associated with an increased stroke risk after transcatheter aortic valve replacement (TAVR), according to new research published in Catheterization and Cardiovascular Interventions.[1] Identifying such warning signs can go a long way toward improving long-term outcomes.
“The rate of stroke following TAVR has decreased from the early experience but is still not negligible, accounting for 1%–3% at 30 days,” wrote Riccardo Gorla MD, PhD, an interventional cardiologist with I.R.C.C.S. Policlinico San Donato in Italy, and colleagues. “As TAVR is progressively expanding to lower risk and younger patients, identification of risk factors for stroke is of increasing importance for patient selection and management.”
Gorla et al. examined data from more than 2,700 patients with severe aortic stenosis who underwent transfemoral TAVR in Italy from December 2016 to September 2018. The mean patient age was 81.8 years old, and 52.3% were women.
Patients were treated with TAVR systems designed by Medtronic, Edwards Lifesciences, Boston Scientific and Abbott Vascular. A total of 35 patients—1.3% of the study’s patient population—experienced a stroke within 30 days. That number increased to 65 patients (2.4%) after six months.
Diabetes, a lower LVEF, a lower estimated glomerular filtration rate, moderate-to-severe mitral regurgitation, critical status and a EuroSCORE II higher than 4% were all more common among patients who experienced a stroke within 30 days of TAVR. In addition, a history of neurological dysfunction, a bicuspid aortic valve and a Geriatric Status Scale of two or three were all more common in patients who experienced a stroke within six months.
The authors ran additional analyses to determine which of these patient factors was associated with a greater risk of post-TAVR stroke. Overall, diabetes and a LVEF less than 50% were defined as “independent predictors of 30-day stroke.” Diabetes, a history of neurological dysfunction and critical status were predictive of a stroke within six months of TAVR.
Meanwhile, the TAVR system used did not impact a patient’s overall risk of stroke. In fact, the only significant procedural factor consistently linked to a heightened stroke risk was aortic valve predilatation, which was performed in 43.3% of TAVR cases. Gorla and colleagues emphasized that the potential link between aortic valve predilatation and post-stroke TAVR remains complicated.
“The decision to perform predilatation often relies on the operator's choice, mainly based on the degree of calcification of the aortic valve, which may itself be an independent predictor for thromboembolic events,” the authors wrote. “Thus, although statistically significant, a causal relationship between predilatation and the risk of stroke cannot be clearly expressed.”
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