“Keep it fast and simple” to avoid periprocedural stroke after TAVI

Holger Eggerbrecht
Holger Eggerbrecht

At PCR London Valves (18–20 September, London, UK), Holger Eggebrecht (Cardioangiological Center Bethanien and AGAPLESION Bethanien Hospital, Frankfurt, Germany) will give the talk “Preventing postprocedural stroke using cerebral protection: which patients and which device?” In this interview with Cardiovascular News, he talks about the risk of periprocedural stroke after transcatheter aortic valve implantation (TAVI) and the steps that can be taken to reduce this risk—including the use of cerebral protection.

With current generation TAVI devices, what is the risk of periprocedural stroke?
According to the German AQUA registry, the risk of clinically overt stroke with TAVI was 1.4% in 2014. Recent meta-analyses (of literature published mostly between 2010 and 2012) reported stroke rates of approximately 3%

Any there are procedural characteristics that could increase the periprocedural risk of stroke?
The data are not consistent but acute, procedural stroke—within 24–48 hours—is linked to procedural complications (second valve, post dilatation). Early stroke is related to new onset atrial fibrillation.

Are there any patient characteristics associated with the risk of periprocedural stroke?
Recently, female gender and older age, as well as the presence of aortic atheroma, have been identified to be associated with increased stroke rates.

Generally what steps can be taken to reduce the risk of periprocedural stroke?
The principle is to perform quick and straightforward procedures, avoiding complications. We should aim to keep it fast and simple.

What devices are available to reduce the risk of stroke?
There are filter and deflection devices that are used for potential prevention of stroke

What data are available for these devices?
So far, data are very limited for both—particularly with respect to patient numbers (three studies with less than 100 patients each). Filter/deflection devices have showed modest impact on new MRI lesions after TAVI. However, at present, prevention of clinical stroke has not been shown.

What further data are needed?
We need larger scale, multicentre randomised trials.

If using a cerebral protection device, what are the factors to consider when choosing which device to use?
That is a difficult question! Filter devices need additional radial/brachial artery access whereas a deflector needs larger contralateral groin access. Also, a filter allows you to evacuate the embolized material from the body but a deflector guides them to the peripheral vasculature.

In your view, which patients could benefit the most from embolic protection devices?
At the moment, the default should be no protection device. Again, keep the TAVI procedure fast and simple. We do not have sufficient data to predict which patient may benefit from protection devices.

Are there any patients who would not benefit from these devices?
Unstable patients, since the procedure takes longer with protection devices