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Several predictors for cerebrovascular event (CVE) incidence following transcatheter aortic valve replacement (TAVR) were recently identified in an analysis published in the Journal of the American College of Cardiology.
Vincent Auffret, MD, MSc, of the Quebec Heart & Lung Institute at Laval University in Canada, and colleagues reviewed studies that reported CVE incidence post-TAVR procedure. They collected data from 64 studies that included 72 318 patients (mean age range: 78.6-84.5 years).
They used a pre-determined hierarchical order to define the single outcome used for each study: “30-day stroke/transient ischemic attack (TIA); 30-day all stroke; 30-day major stroke; in-hospital stroke/TIA; in-hospital all stroke, and in-hospital major stroke.”
Within 30 days after TAVR, 2385 patients experienced a CVE, with an overall incidence ranging from 1% to 11% (median: 4%). Researchers noted a lower risk for men (relative risk [RR]: 0.82; 95% confidence interval [CI]: 0.70-0.97; P=.02). Higher risks were documented for patients with chronic kidney disease (RR: 1.29; 95% CI: 1.03-1.63; P=.03), with new-onset atrial fibrillation (RR: 1.85; 95% CI: 1.20-2.84; P=.005), and for patients whose procedures were performed “within the first half of center experience” (RR: 1.55; 95% CI: 1.16-2.08; P=.003).
Dr Auffret and colleagues also observed a higher CVE risk with balloon post-dilation (RR: 1.43; 95% CI: 0.97-2.10; P=.07). Conversely, valve type (eg, balloon-expandable vs self-expandable; P=.26) and approach (eg, transfemoral vs nontransfemoral; P=.81) did not predict CVE, although the femoral artery was the most common approach.
“It has been shown that among AS [aortic stenosis] patients, women demonstrated a 50% lower risk of stroke over a follow-up of 4 years despite a more severe valvular disease phenotype at baseline,” the authors wrote. “Our data could indirectly suggest a specific TAVR-related risk in women.”
Interestingly, the presence of diabetes, peripheral vascular disease, or coronary artery disease was not associated with CVE following TAVR in this analysis. Regarding chronic kidney disease, researchers commented that the lack of definitive guidelines on anticoagulation therapy for stroke prevention in patients with severe disease may be a possible explanation for the increased CVE risk.
The analysis did have several limitations: variables in stroke reporting across the studies forced investigators to pool different outcomes, a lack of statistical power in certain areas, and an inability to determine “the independent impact of each predictor.”
Dr Auffret and colleagues pointed out while CVE incidence has reportedly decreased, it is still a major complication—particularly since TAVR is due to expand to patients at lower surgical risk.
“Further studies are needed to define the impact of reducing balloon post-dilation, embolism protection devices, and anticoagulation therapy as measure that might influence the risk of stroke in patients undergoing TAVR,” they concluded.
Reference
Auffret V, Regueiro A, Del Trigo M, et al. Predictors of early cerebrovascular events in patients with aortic stenosis undergoing transcatheter valve replacement. J Am Coll Cardiol. 2016;68(7):673-684. doi: 10.1016/j.jacc.2016.05.065.
