Late cerebrovascular events (LCVEs) are common after transcatheter aortic valve replacement (TAVR), and older age, history of cerebrovascular disease, higher aortic gradient, periprocedural stroke, and the lack of anticoagulation at discharge were found to be associated with an increased risk for LCVEs, according to study results published in JACC: Cardiovascular Interventions.
While TAVR has become very useful for patients with severe symptomatic aortic stenosis at intermediate to high surgical risk, one of the most worrisome complications is periprocedural stroke. Because limited data are available on the LCVE post TAVR, the goal of the current study was to explore the incidence, clinical characteristics, associated factors, and clinical outcomes of LCVE >30 days following TAVR.
The multicenter study included 3750 patients (mean age 80±8 years, 50.5% women) from centers in Canada, France, and Spain who underwent TAVR and survived >30 days after the procedure. Most procedures (80.5%) were performed through the transfemoral approach. In-hospital stroke occurred in 2% of patients, and 34.6% of patients were discharged on anticoagulation therapy.
After a median follow-up of 2 years, a total of 192 (5.1%) patients had LCVEs, with an annual incidence ranging from 1.5% to 2.1%. The LCVEs consisted of a stroke and a transient ischemic attack event in 154 (80.2%) and 38 (19.8%) patients, respectively. The stroke was of ischemic, hemorrhagic, and undetermined origin in 124 (80.5%), 29 (18.8%), and 1 (0.7%) patients, respectively.
The risk for late ischemic stroke was higher with older age (hazard ratio [HR] 1.02 for each 1-year increase; 95% CI, 1.02-1.06), history of cerebrovascular disease (HR 1.87; 95% CI, 1.57-2.21), higher baseline mean aortic gradient (HR 1.05 for each 10 mmHg increase; 95% CI, 1.01-1.09), periprocedural stroke at the time of the TAVR procedure (HR 3.21, 95% CI, 1.46-7.07), and lack of anticoagulation therapy at hospital discharge (HR 1.41, 95% CI, 1.20-1.64).
Late stroke was disabling in 107 (69%) patients and associated with an in-hospital mortality rate of 29%. Among hemorrhagic stroke patients, disabling status and in-hospital mortality rates increased to 79% and 66%, respectively. All-cause mortality rate at the end of follow-up among patients with LCVEs was 48%, and the mortality risk was higher for patients with LCVEs following TAVR (HR 1.34; 95% CI, 1.12-1.59).
The researchers acknowledged several study limitations, including retrospective data analysis, unavailable CT data for evaluation of subclinical valve thrombosis, and lack of recorded data on the specific treatments during the LCVE.
“These data may be considered in further studies regarding potential preventive measures of LCVEs following TAVR,” the researchers concluded. They also note that “Most late stroke events were disabling and associated with very high early and late mortality rates, further highlighting the importance of future efforts to both reduce their occurrence and implement the most appropriate therapies to improve outcomes.”
Muntane-Carol G, Urena M, Munoz-Garcia A, et al. Late cerebrovascular events following transcatheter aortic valve replacement [published online March 11, 2020]. JACC Cardiovasc Interv. doi: 10.1016/j.jcin.2019.11.022.